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PRACTICAL    JIANUAL    OF 

DISEASES    OF    WOMEN 

AND 

UTEKINE    THERAPEUTICS 


PRACTICAL    MANUAL 


OP 


DISEASES   OE  WOMEN 

AND 

UTEEINE    THEEAPEUTIGS 
fov  students  anb  practitioners 

BY 

H.    MACNAUGHTON-JONES,    M.D.,   M.Ch. 

MASTER   OF   OBSTETRICS    (HONORIS   CACSA),    KOTAL   UNIVEKSITV   OF   IRELAND  ; 

FELLOW    OF    THE    ROYAL   COLLEGES   OF   SURGEONS   OF   IRELAND   AND   EDINBURGH  ; 

FORMERLY   UNIVERSITY   PROFESSOR  OF   MIDWIFERY   AND  DISEASES  OF   WOMEN   AND   CHILDREN 

IN   THE   queen's   UNIVERSITY 

AND    EXAMINER   IN    MIDWIFERY    AND  DISEASES   OF   WOMEN    AND   CHILDREN   IN   THE 

ROYAL   UNIVERSITY   OP  IRELAND; 

EX-PRESIDENT   OF   THE   BRITISH   GYNECOLOGICAL   SOCIETY  ; 

CORRESPONDING   MEMBER  OP   THE   GYNAECOLOGICAL   SOCIETY   OF    MUNICH 


NINTH     EDITION 


NEW   YORK: 
WILLIAM   WOOD   &   COMPANY, 

MDCCCCV. 


THE    MEDICAL    GEADCATES 

OF   THAT   UXIVERSITT   WITH   WHICH   HE   WAS, 

FOR   A   PERIOD    OF    TWEXTT-TWO   TEARS,    CONNECTED,    EITHER    AS 

STUDENT   OR   TEACHER, 

THIS    BOOK    IS    INSCRIBED 

BY 

THE  AUTHOR. 


PREFACE   TO   THE   NINTH   EDITION, 


The  present  edition  of  this  work,  appearing  foi'  the  iirst  time 
in  the  University  Series  of  its  Publishers,  has  been  practically 
rewritten.  Many  additions  were  also  necessitated  by  the  clinical, 
operative,  and  pathological  advances  which  have  been  made  in 
the  subject  during  the  last  few  years.  The  endeavour  has  been 
to  bring  the  book  into  line  with  the  most  important  of  these 
advances,  up  to,  and  including,  the  present  year. 

The  aim  is  not,  and  never  has  been,  to  place  in  the  hands  of 
students  or  practitioners  a  superficial  and  sketchy  summary  of 
the  subject.  Rather  has  it  been  the  author's  object  to  give  a 
reliable  digest  of  practice,  and  at  the  same  time  to  embrace 
those  pathological  researches  on  which  alone  a  sure  foundation 
of  clinical  treatment  is  based.  The  forecast  made  in  the  first 
edition,  written  in  1884,  of  the  attitude  of  the  well-educated 
practitioner  of  the  future  in  regard  to  the  management  of  his 
gynsecological  cases,  has  been  more  than  fulfilled.  Extended 
courses  of  study,  residence  in  special  hospitals,  and  post-graduate 
instruction  have  helped  to  strengthen  this  tendency  to  indepen- 
dence of  action.  Yet  it  may  not  be  out  of  place  here  to  remark 
that  there  is  a  grave  and  unavoidable  responsibility  attached  to 
the  performance  of  certain  gynaecological  operations,  among  which 
are  some  of  the  most  serious  and  difficult  in  the  entire  domain 
of  operative  surgery.  These  latter  require  in  the  operator,  not 
only  all  the  instincts  of  the  surgeon,  but  also  a  wide  and  varied 
experience  in  the  field  of  pelvic  surgery.  The  senior  student  and 
the  young-  graduate  or  diplomate  who  are  dcAoting  themselves  to  the 

b 


PREFACE    TO    THE  NINTH  EDITION. 


study  of  certain  special  branches  with  a  viev,^  to  making  these  the 
fulcra  by  means  of  which  they  may  advance  themselves  in  their 
profession,  are  not  satisfied  with  any  surface  knowledge.  Therefore 
this  manual  is  not  an  expression  of  the  author's  personal  experience 
and  views  only,  though  both  these,  and  his  own  methods  of  treat- 
ment and  operative  technique,  are  fully  given.  So  far  as  is 
practicable,  the  teachings  of  many  of  the  most  distinguished  and 
reliable  of  modern  gynaecologists  are  referred  to. 

I  am  much  indebted  to  several  home.  Continental,  and  American 
colleagues  for  the  generous  manner  in  which  they  have  accorded  me 
permission  to  use  their  illustrations,  and,  in  several  instances,  have 
given  me  cliches.  Of  these  I  have  to  specially  thank  Sir  Halliday 
Croom  for  his  generous  gift  of  the  three  coloured  plates  of  chorion- 
epithelioma  ;  and  Mr.  Teacher  also,  for  the  photographs  which 
appear  in  the  same  chapter,  and  for  his  valuable  advice  in  the 
Avriting  of  it.  Dr.  Howard  Kelly,  with  his  characteristic  liberality, 
placed  any  or  all  of  his  hitherto  published  illustrations  that  I  might 
desire  to  use  at  my  disposal.  Professor  Bumm  (Berlin)  kindly 
sent  me  some  original  drawings,  and  accorded  me  permission  to 
use  some  of  his  plates,  from  his  magnificent  work,  in  the  chapter 
on  extra-uterine  pregnancy,  which  has  been  rewritten  under  the 
capable  hand  of  Mr.  Frederick  Edge  (Wolverhampton),  and  further 
enhanced  by  Mrs.  Mary  Scharlieb  through  her  most  interesting 
illustration  of  early  tubal  rupture.  Dr.  Pincus  (Dantzig)  has 
favoured  me  with  cliches  from  his  work  on  '  Atmocausis  and 
Zestocausis.'  To  Dr.  Murphy  (Chicago)  I  am  under  an  obligation 
for  the  assistance  derived  from  his  comprehensive  brochure  on 
'  Tuberculosis  of  the  Female  Genitalia,'  and  to  Dr.  Comyns 
Berkeley  for  the  facts  collated  by  him  in  his  paper  on  the  same 
subject.  In  the  revision  of  the  chapter  on  the  rectum,  I  have 
had  the  assistance  of  my  friend  and  coadjutor,  Mr.  Charles  By  all. 
For  pathological  reports,  I  have  to  reiterate  my  acknowledgments 
made  in  previous  editions  to  Mr.  Targett,  In  this  one  I  am 
particularly  indebted  to  Dr.  Cuthbert  Lockyer  and  Mr.  Sampson 
Handley ;  also  to  Dr.  Eastes  for  the  preparation  of  specimens, 
macroscopieal    and   microscopical.     Through   the    courtesy  of    Drs. 


PREFACE    TO    THE  XTXTH   EDITWX.  ix 

C.  J.  Ciillingworth  and  T.  W.  Eden,  I  have  been  enabled  to  pourtiay 
the  rare  condition  of  hydatid  of  the  ovary  and  Fallopian  tube. 

To  many  Continental  friends,  from  whom  I  have  received  both 
courtesy  and  kindness  while  visiting  their  clinics,  I  take  this 
opportunity  of  tendering  my  thanks.  Much  that  appears  in  this 
work  is  due  to  the  experience  gained  through  those  visits.  If  I 
particularize  the  Frauenkliniks  of  Professors  Olshausen,  A.  Martin, 
Paul  Zweifel,  Schauta,  Chrobak,  Winckel,  Gustav  Klein,  Leopold, 
Kleinhans  (the  successor  of  the  illustrious  Sfinger),  Kronig  and 
Menge,  Bumm  and  Schultze,  it  is  because  in  these  I  have  had 
more  ample  opportunities  of  seeing  the  details  of  their  different 
techniques. 

Through  the  journal  of  the  British  Gynaecological  Society  and 
that  of  Obstetrics  and  Gynsecology  of  the  British  Empire,  I  have 
obtained  material  that  otherwise  I  could  not  have  hoped  to  secure. 
The  summary  of  the  subject  in  the  former  journal,  by  its  editor. 
Dr.  J.  J.  Macan,  I  have  freely  availed  of.  All  excerpts  and  refer- 
ences are  duly  noted  throughout  the  pages  of  the  work. 

In  passing  this  work  through  the  press,  I  received  material 
assistance  from  Dr.  8.  Jervois  Aarons,  who  read  all  the  first  proofs ; 
while  ■  the  labour  of  correcting  revises,  compiling  the  index,  the 
lists  of  illustrations,  and  the  names  of  authorities,  was  undertaken 
by  another  friend. 

The  greater  number  of  the  plates  throughout  the  work  were 
drawn  by  Mr.  S.  A.  Sewell,  and  faithfully  delineate  the  patho- 
logical conditions  they  represent.  Messrs.  Arnold  k  Son  have 
provided  me  with  several  new  engravings  of  appliances,  executed 
especially  for  this  edition.  As  hitherto,  my  publishers  have  spared 
neither  trouble  nor  expense  in  the  production  of  the  book. 


H.    MACXAUGHTOX-JONES. 


131,  Harley  Street,  \V. 
October,  1904. 


CONTENTS. 


CHAPTER    I. 

PAGES 

Anatomical  and  Clinical — Summary  of  Anatomical  Facts  which 

have  a  Bearing  on  Gynaecological  Diagnosis  and  Practice         .  l-oO 


CHAPTER   II. 

FiiJ.sT  Stkps  of  Examination  of  a  Case        .....         51-82 

CHAPTER   III. 

FiiJST  Steps  of  Examination  of  a  Case  (continued')       .         .         .       S3-10G 

CHAPTER  lY. 

Asepsis  and  Antisepsis  in  Gynecological  Surgery       .         .         .     1U7-141 

CHAPTER   Y. 

Some  Minor  Gynecological  Operations       ...  .     142-161 

•CHAPTER   YI. 

Some  Remarks  on  Sutuees  and  Ligatures    .....     162-170 

CHAPTER  VII. 

Disorders  of  Menstruation — Amenorkhcea  and  Leucorrhcea         .     171-185 

CHAPTER   YIII. 
Disorders  of  Menstruation  (continued) — Dysmenorrhcea       .         .     186-210 

CHAPTER  IX. 

Uterine  Neuroses  and  Reflexes  ......     211-219 


xii  CONTENTS. 


CHAPTER  X. 

PAGIS 

Affections  op  the  Female  Gte^jitalia  and  their  Special  Bearing 
ON  THE  Operative  Treatment  of  the  Insane — Physiological 
and  Psycliopathic  Considerations     ......     220-232 


CHAPTEPt  XI. 

Uterine  Displacements — Important  Displacements         .         .         .     233-244 

CHAPTER  XII. 

Uterine  Displacements  (cojiiMiMefZ)— Retroversion  and  Retroflexion     245-277 

CHAPTER   XIII. 

Uterine  Displacements  {continued) — Prolapsus      ....     278-312 

CHAPTER   XIV. 

Uterine  Displacements  (continued) — Inversion  of  the  Uterus         .     313-325 

CHAPTER  XV. 

Inflammation  of  the  Uterine  Tissues — Acute  and  CHR0N^c         .     326-351 

CHAPTER   XVI. 

Erosion,  Granular  and  Follicular  Degeneration  of  the  Cervix    352-358 

CHAPTER   XVII. 

Pelvic  Inflammation .         .         .     359-r377 

CHAPTER   XVIII. 
Pelvic  H-emorrhage 378-385 

CHAPTER  XIX. 

Laceration  of  the  Cervix  .         .         .         .         .        ■•         .         .     386-391 

CHAPTER  XX. 

Uterine  Neoplasms— Polypus  Uteri     .' 392-398 


CONTENTS. 


CHAPTER   XXI. 

I'AGKS 

Utkrine   Neoplasms   (continued) — Myoma — Etiological  and  Patho- 
logical        399-424 


CHAPTER  XXII. 

Utekine    X'eoplasms — JIyoma    (continued) — Differential    Diagnosis 

and  Palliative  Treatment 425-434 


CHAPTER  XXIII. 

Uterixe   Neoplasms — Myoma  (continued) — Pregnancy  complicating 

Myoma — Differentiation — Diagnosis  and  Treatment  .  .     435-444 


CHAPTER   XXIV. 

Uteiuxe  Neoplasms — Myoma  (continued) — Surgical  Treatment     .     445-455 

CHAPTER   XXV. 

Uterixe  Neoplasms — Myoma  (continued) — Surgical  Treatmext     .     456-474 

CHAPTER   XXVI. 

Uterixe  Neoplasms — Myoma  (contimted) — Surgical  Treatmext     .     475-504 

CHAPTER    XXVII. 

Uterixe  Neoplasms — Myoma  (continued) — Surgical  Treatmext     .     505-514 

CHAPTER   XXVIII. 

Uterixe  Neoplasms — Myoma — Surgical  Treatmext  (continued)     .     515-533 

CHAPTER   XXIX. 

Surgical  Treatmext  op  Uterixe  Myoma  (continued)    .         .         .     534-549 

CHAPTER   XXX. 

Caxcee  of  the  Uterus  .         .         .         •         .         •         •         •     550-566 

CHAPTER   XXXI. 
Caxcer  of  the  Uterus  (continued)        ......     567-579 


xiv  CONTENTS. 


CHAPTER    XXXIl. 

PAGES 

Cancke  or  THE  Uteel's  {continued) 580-604 


CHAPTER   XXXIII. 
Choeiox-Epithelioma 605-619 

CHAPTER   XXXIV. 

TcBEKCDLOsis  OF  THE  Female  Gexitalia        .  .  .      '    .  .      G20-647 

CHAPTER   XXXV. 

Affections  of  the  Fallopian  Tubes 648-687 

CHAPTER   XXXVI. 
Extka-uteeine  Peegnancy 688-717 

CHAPTER   XXXVII. 

Affections  of  the  Ovaeies — Ovaeitis 718--735 

CHAPTER  XXXVIII. 

Ov  Alii  AN  Cystoma — JLtiology  and  Pathology      ....     736-750 

CHAPTER   XXXIX. 

Ovakian  Cystoma — Diagnosis  and  Teeatment       ....     751-766 

CHAPTER.  XL. 

Classification  and  Pathology  of  Solid  Tumoues  of  the  Ovaey      767-778 

CHAPTER   XLI. 

Affections  of  the  Ovaeies  {continued) — The  Operations  of  Salpingo- 
oophorectomy  and  Ovariotomy  for  Ovarian  Cystoma,  Abdominal 
and  Vaginal 779-797 

CHAPTER   XLII. 

Affections  of  the  Vulva     .         .         .     •    .         .         .         .         .     798-836 


CONTENT.^. 


CHAPTER   XLIir. 
Affections  of  thk  ^'AGI^•A 837-882 


CHAPTER  XLIV. 
Affectioxs  of  the  Uketuha 883-893 

CHAPTER   XLV. 
Affections  of  the  Female  Bladder 894-919 

CHAPTER   XLVr. 
Affections  of  the  Ueeteks 920-944 

CHAPTER    XLVII. 
AfFE<  TIONS  <>F  THE  KlUNEY    ........      945-964 

CHAPTER   XLVIII. 
Some  Affections  of  the  RECTUii  ......     965-989 

CHAPTER   XLIX. 
Stekilitt 990-998 

CHAPTER   L. 
Gynecological  Electro-Therapeutics         .....     999-1007 

CHAPTER   LI. 
Massage 1008-1017 

CHAPTER  LII. 

Some  European  Spas  indicated  in  Pelvic  and  other  Associated 

Affections  of  "Women '        .         .         .  1018-1021 

i^'DEX 1023-1034 

Illustrations  of  Instruments  and  Appliances  .         .         .     1035-1037 

List  of  Authorities  ........     1038-1044 


LIST    OF    ILLUSTRATIONS. 


FIG.  FACE 

1.  The  Vulva  (Sharpey)   ........         .2 

2.  Kelly's  Ukethal  Oalibkator        .......        4 

3.  Seotiox  of  the  Body  of  a  "Woman  (after  Heitzman)      ...         6 

4.  Sectiox   showing  Distesded   Kectdm    and  Empty   Bladder   (from 

Braune)      .....         o         ...         . 

5.  Section  showing  Distended  Bladder  (from  Braune)       ...         7 
0.  Position  of  Body  in  the  Genu-pectoral  Position         .         .         .         y 

7.  View  of  the  Viscera  (Howard  Kelly)  ......       10 

8.  Vertical  Section  of  Uterus  (Eamsbotham)  .....       13 

9.  Lateral  Section  of  Uterus  (Eamsbotham)  .         .         .         .         .15 

10.  Uterus  pressed  upon  by  Distended  Bladder  and  Kectum  (Braune)       15 

11.  Normal  Position  of  Virgin  Uterus  (Schultze)      .         .         .         .15 

12.  Eelative  Position  of  Pelvic  Viscera  (A.  Farre)  .         .         .         .16 

13.  Position  op  the  Pelvic   Organs  in  the  Erect  Position  (Hegar) 

{facing)  16 
18a.  Position  of  the  Pelvic  Organs  m  the  Dorsal  Position  (Hegar) 

{facing)  16 
136.  Position  of  the  Pelvic  Ojjgans  in  the   Dorso-sacral    Position 

(Hegar) {facing)  17 

13c.  Position  of  the  Pelvic   Organs  in  the  Dokso-lumbar  Position 

(Hegar) {facing)  17 

14.  Diagrammatic  View  of  Uterus  and  Appendages  (Quain)       .         .       19 


Tube 


15.  Vascular    Kelations    of    Uterus,    Ovary,   and   Fallopian 

(Howard  Kelly) 

16.  Diagram  of  Uterus  to  Show  Division  op  Cervix.  (Shrceder) 

17.  CoNGE^^TAL  Stenosis      ....... 

IS.  Lymphatics  of  the  Pelvic  Organs  (Howard  Kelly) 

19.  Di.\gram  of  the  Vascular  Sxtpply  of  the  Vagina,  Uterus,  and 

Ovary  (Hyrtl) 

20.  Normal  Fallopian  Tube  in  Section  (Macalister)  . 

21.  Vertical  Section  through  the  Broad  Ligament  (Anderson) 

22.  Section  of  the  Pelvis  showing  the  Ligaments  of  the  Uterus 

(Anderson)  ........ 

23.  Ovarian  Arterial    Supply    and    Distribution    of    the   Ovaeian 

Artery  (Howard  Kelly)      .         .  ... 

24.  Uterus  during  Menstruation  (Gallard) 

25.  Showing  Relation  op  Uterus  to  Uterine  Arteries,  Ureters,  and 

Bladder  (Greig  Smith) 46 


LIST   OF  ILLUSTRATIONS. 


FIG. 

2G.  Pelvic  Portion  of  TJeetek  from  below 

27.  Diagrammatic    Figure    showing    the    Position    of    the    Ureter 

accessible  to  the  examining  finger 

28.  Showing  the  Disturbed  Eelation  of  Parts  when  the  Uterus  is 

DRAWN  DOWN  (Greig  Smith) 

29.  Patient  in  Semi-peone  Position    . 

30.  End  of  Couch,  with  Leg  Eests  adjusted  . 
ol.  Leg  Support  ...  .  . 
.32.  Crutch  of  Von  Ott      ..... 

33.  Portable  Table  foe  Trendelenburg's  Position 

34.  Position    of    Hands    and     Fingers    in    Bimanual     Examinatcon 

(Howard  Kelly) 

35.  Table  for  Abdominal  Operations 

36.  TA1.LE  in  the  Trendelenburg  Position 

37.  Table  adjusted  for  Vaginal  Operations 

38.  Patient  on  Doyen's  Table  in  Complete  Trendelenburg  Position 

39.  Microscopical  Appearances  of  Anomalous  Ovarian  Tumours 

40.  Metal  Vulcanite-covered  Duckbill  Speculum  (Leiter) 

41.  Vulcanite-coated  Speculum  and  Dressing  Forceps 

42.  Author's  Tapering  Speculum  with  Bevelled  and  Cushioned  End 

43.  Sims'  Hook    .... 

44.  Single  Tenaculum  Forceps   . 

45.  Sims'  Duckbill  Speculum 

46.  Neugebauer's  Speculum 

47.  Fergusson's  Speculum    . 

48.  Author's  Tubular  Speculum  Slice 

49.  Bath  Speculum 

50.  Eectangular  Specclum  Forceps 

51.  Author's  Demonstration  Speculum 

52.  Appliance  Folded 

53.  Simpson's  Sound    . 

54.  Sims'  Pliable  Probe 

55.  Author's  Small  Portable  Sound 

56.  Author's  Combination  of  Elevator  and  Sound 

57.  First  Stage  op  Passing  the  Sound  (Hart  and  Barbour) 

58.  Second  Stage  of  Passing  the  Sound  (Hart  and  Barbour) 

59.  Sound  in  Utero;  Eecto-uteeine  Examination 
GO.  Proper  and  Improper  Methods  of  Eotatiok  op  the   Sound  (Hart 

and  Barbour)       .         .         .         .         .     -    . 

61.  Eecto-vesical  Examination  .... 
6 1  a.  Vernon  Harcourt's  Chloroform  Eegulator 

62.  Chloroform  and  Ether  Inhaler  . 

63.  Tupelo  Tent 

64.  Sponge  Tent  ...... 

65.  Forceps  for  introducing  Tents    . 

66.  Natural  Size  of  Smaller  Laminaeia  Tents 

67.  Light  .Vulcanite  Dilators    .... 

68.  Author's  Graduated  Bulbous  Aluminium  Bougies 

69.  Hegar's  Dilators 

70.  Case  of  Seven  Bougies 

71.  Eecto-vesical  Examination  in  Complete  Inversion 


PAGE 

48 


L Is T   (I F   11.1  J 'S Ti: Alio S^. 


72.  Bahtlkit's  Aspirator  ...... 

73.  AsPIKATOli     ........ 

71.  Aspirating  Nei:i>les     ...... 

75.  Genital  Organs  from  Female  Child  (George  Carpenter) 

76.  rELVic  Organs  of  a  Female  Child  (George  Carpenter) 

77.  Central  CHOKoino-RETiNiTis 

78.  HiEMoRRH.\Gic     Infarctions    folloaving     Albximinuhic    Retiniti 

DURING  Pregnancy    ...... 

79.  Choked  Optic  Papilla  during  Suppression  op  the  C 

80.  Same  Papilla  mhen  recovering  . 

81.  Ryall's  Expanding  Rectum  Speculum 

82.  Davy's  Rectal  Speculum     . 

83.  Go'wland's  Rectal  Speculum 

84.  Vulcanite  and  Glass  Syringe     . 

85.  Electric  Lamp  with  Reflector 
8G.  Standard  Lamp  with  Bull's-eye  Reflectoi; 

87.  Movable  Lavabo  .... 

88.  Lavabo  for  Artificial  Serum 

89.  Needle  for  Artificial  Serum 

90.  The  Trendelenburg  Position 

91.  Aujustable  Frame  for  Trendelenburg's  Position 

92.  Greig  Smith's  Table   .... 

93.  Nickel  Box  for  Sterilizing  Needles 

94.  Dry  Stove  for  Instruments 

95.  Nickel  Box  for  placing  in  Sterilizei; 

96.  Small  Yapocr  Sterilzier    . 

97.  Glass  Reel  for  Gut   .... 

98.  Hermetically'  closed  Vulcanite  and  Glass  Jar 

99.  Vulcanite  Cap 

100.  Glass  Needle-case  for  Sterilized  Needles 

101.  Assistant  keady  for  Operation  . 

102.  Surgeon  with  Overalls  and  Waterproof  Api;on 

103.  Aseptic  Nailbrush  with  Box 

104.  Nickel-plati;d  Vagina  Douche  Pipe     . 

105.  Flushing  Vaginal  Retractor 
105a.  Tap  wti-h  Adjustable  Nozzle    . 
100.  Catheter  Sterilizer    . 

107.  Metal  Basket  with  Pedal-acting  Cover 

108.  Glass  Cathi:ter  ..... 
108a,  1086.  Aseptic  Mask  of  Author  . 

109.  Exact  Size  of  Holder  covered  with  Wool 

110.  Roughened  End  of  AVool-holder 

111.  Hall's  Lancet     ..... 

112.  Sattler-Nieden  Universal  C.\utery  Handle,  with  Sn 
llo.  Porcelain  Cautery      .... 

114.  Kuchenmeister's  Scissors     . 

115.  Marion  Sims'  Kntfe     .... 
HO.  Author's  Celluloid  Wire  Stem  . 

117.  Syphon  Trucar  of  Spencer  Wells 

118.  Trocar  and  Cannula  .... 

119.  Fine  Aspirating  Trocar  and  Cannula 


Vh(,V. 

90 
90 
90 
93 
94 
100 

101 

102 

102 

105 

105 

100 

106 

112 

112 

113 

113 

114 

115 

115 

115 

116 

117 

118 

119 

120 

120 

120 

121 

123 

124 

125 

1 29 

130 

130 

134 

135 

1.3!; 

141 

143 

143 

143 

144 

144 

145 

145 

146 

MC 

no 

MS 


LIST   OF  ILLUSTRATIONS. 


PIG.  PAGE 

120.  Kcebeele's  -Tkocae  and  Cannula 148 

121.  Teocar  and  Cannula  for  Pelvic  Abscess 149 

122.  Pokte-caustique  for  the  Introduction  of  Braxton  Hick's  Fused 

Sticks 154 

123.  Author's  Intra-uterine  Medicator      ......  154 

124.  Small  Platinum  Crucible  ........  155 

125.  126,  127.  Various  Uterine  Curettes    ......  156 

128.  Curved  Blade  op  Landau's  Knife       ......  156 

129.  Light  Metal  Spoon  Curette 157 

130.  Martin's  Curette 157 

131.  Noble's  Curette  Forceps    ........  157 

132.  Slender  Clamp  Forceps 158 

133.  Slender  Intba-uterine  Forceps 158 

134.  Vertical  Section  of  Uteeus  Three   Months   after   Curettage 

(Baldy) 159 

135.  Czernt's  Suture 162 

136.  Lembert's  Suture 162 

137.  Gussenbaur's  Suture 162 

138.  Position    op    the    Three    Threads    in    the    Suture    'a    Points 

Separes'   ...........  163 

139.  Simple  Continuous  Suture  commenced 163 

140.  Continuous  Suture  nearly  finished   ......  163 

141.  '  Suture  a  Etages  ' 164 

142.  Surgeon's  Knot  .         .         .         .         .         .         .         .         .         .  164 

143.  144.  Ordinary  Loop-exot  for  Pedicle  (Doran)    ....  164 

145.  Bantock's  Knot 165 

146.  Tait's  '  Staffordshire  '  Knot      .......  165 

147.  Chain  Ligature  or  Pedicle,  Threads  crossed  (Doran)         .         .  165 

148.  Chain  Ligature  on  a  Membranocs  Pedicle         ....  165 

149.  150.  Showing  the  Method  of  making  Consecutive  Loops     .         .  165 

151.  Loops  of  Chain  Ligature 165 

152.  Showing  Threads  crossed,  knotted,  and  ready  for  Tightening  165 

153.  Post-operative  Abdominal  Hernia      ......  167 

154.  Method  op  closing  the  Abdominal  Wound          ....  167 

155.  The  Same  after  Operation         .......  168 


156.  Zweipel's  Needles 

157.  Portable  Can  Douche 

158.  Degrees  of  Anteversion 

159.  Galabin's  Pessary 

160.  Anteversion  Pessary  , 

161.  Hewitt's  Pessary 

162.  Fowler's  Pessary 


169 
205 
233 
237 
237 
238 
238 


163.  Anteflexions  of  Uterus  (Schrceder)    .  .         .         .         .         .  239 

164.  Sims'  Operation  for  creating  New  Uterine  Axis       .         .         .  241 

165.  Bilateral  Division  of  the  Cervix  with  Kuchenmeistek's  Scissors  241 

166.  Dilator  for  stretching  Cervical  Canal    .         .         .         .  .  242 

167.  Dudley's  Operation — Application  of  Sutures  (Keith)         .         .  243 

168.  Supra-Pubic  Support -     .         .         .  244 

Fourteen    Diagrammatic    Figures    representing     Positions    of 

Pessaries  used  by  Author         .         .         .         .         .         {facing)  244 

169.  Degrees  op  Retroversion  (Schrceder)  .......  249 


L  fST   OF   fL L  UlHTliA  TfOXFi. 


TON  (Hart  and  Barbour) 


FOR 


Uterus 


Protection'  of   the 


FKi. 

170.  Eetroflexion  (Schrceder)     . 

171.  Introduction  op  Sound  before  IIotat 

172.  RoT.\Tiox  OF  Sound  in  Retroversion 

173.  Thomas's  Modified  Smitu-Hodge 

174.  Arnold's  Glycerine  Pad     . 

175.  First  Step  of  Introduction  of  Sound 

176.  Second  Step  of  Introduction 

177.  Smith-Hodge  Pessary  in  Position 

178.  Celluloid  Ring  . 

179.  Same  finally-  Moulded 

180.  First  Shape  op  Ring  . 

181.  Second  Shape      .... 

182.  Third  Shape        .... 

183.  Celluloid  Cushion  Pessary 

184.  Schultze's  Sledge-shaped  Pessary 

185.  Ligatures  passed  through  Peritoneum  and 

186.  Uterus  suspended 

187.  Orthmann's  Instrument 

188.  A.  Martin's  Perineal  Retractor 

189.  Vulcanite  Pipette      .         .         . 

190.  Martin's    Large    Conical    Retractor 

Bladder  .         .         .         .         .         . 

191.  Martin's  Needle-holder     . 

192.  Curved  Hysterectomy  Needles  (Martin's) 
19o.  Showing  Gradual  Descent  op  the  Uterus  (Thomas) 

194.  Prolapse  complicated  vj'ith  Cystocele  (Author) 

195.  Prolapse  -with  Cy'stocele  (after  Schrceder)  . 

196.  Hypertrophic  Elongation  of  Cervix  (Schroeder) 

197.  Relaxed  Vaginal  Outlet  (Howard  Kelly)  . 

198.  Ruptured  Perineum,  Rectocele,  and  Cystocele  (after  Martin) 

199.  Zwancke's  Vulcanite  Pessary  (open) 

200.  Schultze's  Figure-of-Eight  Pessary   . 

201.  Napier's  Prolapse  Pessary 

202.  Braun's  Colpeurynter         ..... 

203.  Absent  Perineum  with  Retroversion  (after  Martin) 

204.  Ruptured  Perineum  and  Cystocele  (after  Martin) 

205.  Self-retaining  Catheters  (Skene-Goodman) 

206.  Splitting  the  Recto-Vaginal  Septum 

207.  Passage  of  the  Suture        .... 

208.  Wound  closed     .         .         .         . 

209.  Diagram  of  Incisions  ..... 

210.  Ditto  ........ 

211.  DoLERis'  Modification  of  Tait's  Operation 

212.  Rectal  Sutures  not  tied  (Howard  Kelly)  . 

213.  Complete  Tear  of  the  Recto-Vaginal  Septum  (Howard  Kelly)  . 

214.  Rectal  and  Vaginal  Sutures  all  tied  (Howard  Kelly) 

215.  '  Colpoperineoplastie  par  Glissement  '  (Bonnet  and  Petit) 

216.  Sims'  Colporrhaphy      ....... 

217.  Colporrhaphy  Knife  of  Martin  .... 

218.  Anterior  Colporrhaphy,  showing  the   Sutdres   that   close 

Thin  Angles  (Dole'ris;   ....,,, 


I'AGi; 
249 
252 
253 
255 
255 
25IJ 
256 
256 
257 
257 
257 
257 
257 
258 
260 
271 
272 
273 
274 
275 

275 
276 
276 
278 
279 
280 
280 
281 
283 
284 
284 
285 
285 
289 
289 
290 
292 
292 
292 
29:-i 
294 
29 1 
296 
297 
297 
298 
3011 
SOU 

301 


LIST   OF  ILLUSTEATIONS. 


SHOWING     THE     PASSAGE     OP     THE     FiNAL 


nd  Petit) 


FIG. 

219.  Anterior-  Colpoerhapht, 

Suture  (Doleris)       .... 

220.  Keamt's  Operation  foe  Eectocele 

221.  CoLPOPERiNEOEEHAPHY  (Martin's  method) 

222.  Amputation  of  the  Cervix  (Sims) 

223.  Scheceder's  Amputation  of  Vaginal  Ceetix  (Bonnet 

224.  Sectional  View  op  same      ..... 

225.  Dissection  op  the  Uteeus  in  Two  Parts  (Doyen) 

226.  Complete  Seveeance  op  the  Uterus  (Doyen) 

227.  Inversion  op  the  Uterus  (Robert  Barnes)    . 

228.  Partial  Inversion  op  the  Uteeus — Second  Degree  (Bonnet  and 

Petit) . 

229.  Inveeted  Uterus  (Doyen)    .         .         .         . 

230.  Prolapsus  Uterus  (Schroeder)       .... 

231.  Outline  Diagram  op  Complete  Inversion    . 

232.  Outline  Diagram  op  Paetial  Inversion 

233.  Outline  Diageam  op  Polypus  at  Summit  of  Uterine 

234.  Reduction  op  Inverted  Uterus  (Emmet)     . 
285.  White's  Cup  Repositoe  (Thomas) 

236.  Sigmoid  Repositor         .         .         .    '      . 

237.  Sectional  View  of  Complete  Inversion  (Haultain) 
237a.  Ditto  (Haultain) •    . 

238.  Leiter's  Temperature  Coil 

239.  Adeno-Carcinoma  op  Cervix  Uteri 

240.  Papillary  Erosion  of  the  Cervix 

241.  Hemorrhagic  Endometritis  (Shaw-Mackenzie)    . 

242.  '  Catarrhal  '  Endometritis  (Shaw-Macljenzie) 

243.  Endometritis  Hyperplastica  (Author) 
243fl.  PiNCUs'   Improved   Apparatus   foe   Atmocausis 


Cavity 


301 
301 
302 
802 
303 
303 
310 
310 
314 

315 
315 
315 
316 
316 
316 
318 
320 
320 
320 
320 
.329 
334 
334 
335 
335 
336 


AND    ZeSTOGAUSIS 

(facing)  330 
(facing)  336 
(facing)  337 
.     337 


243&.  Uterus  and  Adnexa  removed  by  Atmocausis     . 
243c.  Ditto 

244.  Combination  op  Bell-shaped  Poeceps  . 

245.  Dbessing  the  Ceevix  in  the  Lateral  Position  ....  341 

246.  Epithelial  Denudation  around  the  Os  Uteri  (Robert  Barnes)   .  350 

247.  Erosion  op  the  Cervix  (Author)          .         .         .         .         .         .  353 

•'•48.  Author's  A'aginal,  Uterine,  and  Operating  Insufflator    .         .  356 

249.  Follicular  Degeneration  and  Erosion  with  Slight  Laceration 

(Author) " 357 

249a.  Sharply  Defined  Erosion  with  Lacerated  Cervix  (Author)     .  357 

250.  Sharp  Curette  (Simon's)      . 358 

251.  Follicular  Hypeetrophy  of  the  Cervix  (Pozzi)           .         .         .■  358 
■''52.  Mucous  Polypi  growing  from  the  Interior  op  Cervix  (Pozzi)    .  358 

253.  Collection  op  Serum  in  the  Peritoneal  Cavity  (Schroeder)        .  361 

254.  Tumours  treated  by  Abdominal  Incision  and  Drainage  (Wallace)  362 
254a.  Ditto          ...........  363 

255.  Showing  Adhesion  of   Old   Pedicle   op   eemoved   Adnexa  adhe- 

rent- to  Cecum  and  Appendix           .         ...         .         .         .  365 

256.  Kelly's  Operation  op  Oophoro-Salpingo  Hysterectomy      .         .  368 
256a.  Uterus  Eemoved— Vessels  Ligated— Buried  Sutures  passed     .  369 

257.  Eetro- Hematocele  (Schrceder)    ...         .         .         .         .         .  378 


Tjsr   OF    lUrsTRATfON!^. 


OMA   (Mary 


Ahteuial 
(facing) 


rio. 

25S.  Retro-Uterink  II.ematooele  (Robert  Barues) 

2.')9.  Paquelin's  Cautery  Scrssoits 

200.  Bilateral  liACERATioN         .... 

2G1.  Unilateral  Lacioration       .... 

2G2.  Stellate  Laceration..         .... 

21(3.  Emmet's  Operation      ..... 

2(J-i.  Sutures  passed    ...... 

2U5.  Sutures  applied  ..... 

2GG.  Submucous  Fibroid       ..... 

207.  Outline  DxAGRAii  of  Polypus  up  Cervix  (adapted  fiom  Thomas) 
2(jS.  Outline  Diagram  of  Polypus  with  Long  Pedicle  attached  T( 

Summit  of  Uteiuxe  Catity 
2(!D.  Fibroid  Tumour  of  Uterus  (Barnes)    . 

270.  Fibroid  Polypus  (Robeit  Barnes)  . 

271.  Application  of  Ecraseui;  to  Polypus  . 

272.  "Wire  Conductors         ..... 
278.  Author's  Polyptome    ..... 

274.  JIyoma  op  Pregnant  Uterus  (Alban  Doran) 

275.  FiBROMYOMA  OP  Uterus  (Albau  Doran). 

276.  Section  of  Fibromatous  Uterus  . 

277.  Degenerative    Changes   in    Muscle   Fibres  of   a  My 

Dixon  Jouesj    ...... 

277a.  Showing    Early    Stages    of    Hypertrophy    of    the 

Median  Coat  (Staumore  lUsliop) 
277&.  Considerable  Hypertrophy  of  Muscular  Layer (.StaninoreUishop) 

(facing) 
277c.  Group    of  Arteries   showing  Various   Stages  up   Hypertrophy 

of  Muscular  Layer         ......         (facing) 

278.  Giant  Cystic  Fibromyumata  (Clarence  Webster) 

279.  Sections  from  Fibrocystic  Myoma  (Mary  Dixon  Jones) 

280.  Section  of  Tumour 

28L  Ditto  .  " 

282.  Adenoma  op  the  Uterus  (Landau; 

288.  Adenoma  Universale  (Oliver) 

28i.  Adenoma  of  thi':  Uti:i!Us  diagnosed  as  Myoma 

2S.'').  Uterine  Adenoma  (Murdoch  Cameron) 

2S(J.  Ditto  (F.  E.  Taylor) 

287.  Pyelonephrosis  and  Pyouketek   . 

288.  Pedunculated  Subperitoneal  Fibroid  (Author) 

289.  Retroversion  of  Fibkomatous  Uterus  (Doyen) 

290.  FiBROMYOMA  (Doleris)   ..... 

291.  Pedicul-vped  Fibroma  ..... 

292.  Large  Uterine  Fibroid  (Howard  Kelly) 
29.8.  Specimen  of  Myomatous  Pregnant  Uterus  and 

294.  Interstitial  Fibromata        .... 

295.  Extra-uterine  Gestation  (W.  Duncan) 
290.  Pregnant  Uterus  with  IMyoma  . 

297.  Interstitial  Pregnancy  in  Myomatous  Uterus 

298.  Rossi's  Dilator 

299.  Modifications  of  Rossi's  Dilators  (Frommer  and  Preiss) 

300.  Incision  over  Left  Bro.xo)  Ligament  (Martin)     . 


FCETU 


s  (Elder) 


881 
88 1 
880 
8.S7 
887 
890 
890 
391 
392 
892 

892 
398 
890 
397 
397 
898 
400 
400 
401 

402 

102 

4!»2 

403 
412 
418 
414 
414 
415 
4!7 
418 
410 
419 
423 
420 
420 
427 
427 
480 
4:i0 
487 
438 
480 
440 
443 
444 
J  50 


LIST  OF   ILLUSTBATWNS. 


FIG. 

301. 
302. 
803. 
304. 
305. 
306. 
307. 
308. 
309. 
310. 
311. 
312. 
313. 
314. 
315. 
316. 
317. 
318. 
319. 
320. 
321. 
322. 
323. 
324. 
325. 
326. 
327. 
328. 
329. 
330. 
331. 
332. 
333. 
334. 
335. 
336. 
337. 
338. 
339. 
340. 
341. 
342. 
343. 
344. 
345. 
346. 
347. 
348. 
349. 
350. 
351. 


CCELIOTOMY 


Separation  op  the  Bboad  Ligament  with  the  Fingers 

Grasping  the  Base  oe  the  Broad  Ligament 

Ligaturing  Base  op  Broad  Ligament  . 

Enucleator  ..... 

Fibromyomata  Enucleated  bt  Abdominal 

morcellation  forceps 

Ditto  ..... 

Pean's  Cyst  Forceps  . 

Doyen's  Tube  Tranchant    . 

Forceps  for  use  with  Same 

Morcellation  op  Uterine  Wall 

Morcellation  for  Submucous  Fibroma 

Ditto  ....... 


Application  of  Tube  Tranchant  to  Tumour 
Doyen's  Supka-Pubic  Ketractor  . 
Wells'  H.a!M0STATic  and  Torsion  Forceps 
Slender  Clamp    ..... 

Cook's  Peritoneal  Knife     . 
Forehead  Keflector  .... 

Author's  Glass  Eetractors 

Second's  Bivalve  Eetractok 

Delivery  op  Fibroid  with  Doyen's  Helicoid 

Kocher's  Clamp  Forceps 

Ligature  Hook   .         . 

Curved  Needles  ..... 

Doyen's  Peritoneal  Needle-holder    . 
Olshausen's  Broad  Ligament  Needles 
Ditto  ....... 

Olshausen's  Sharp  Curved  Needle 

Doyen's  Long  Forceps 

Bilroth's  Clamp  .... 

Doyen's  Short  Pressure  Forceps 
Zweipel's  Small  Crushing  Forceps 
Forceps  closed    ..... 

Passage  op  Double  Ligature  (C.  Martin) 
Successive  Ligatures  op  Broad  Ligament  (G.  Martin) 
Ligature  cut  Short  and  Pedicle  dropped  (C.  Martin) 
Poll  op  Iodoform  Gauze  drawn  down  through  Vagina 
Eeverdin's  Needles     ....... 

Doyen's  Helicoid         ....... 

Detachment  op  Eight  Broad  Ligament  (Doyen) 
Doyen's  Erigne  .         .         .         . 

Opening  op  the  Posterior  Vaginal  Cul-de-sac  (Doyen) 
Incision  of  the  Anterior  Cul-de-sac  (Doyen)     . 
Kocher's  Forceps  applied  to  Divided  Broad  Ligament 
Kocher's  Forceps         ....... 

Blunt-pointed  Scissors        .         .         .         .         .         . 

Electro-h.s;mostatic  Clamp  Forceps  (Jacobs)  -     . 
DowNEs'  Electro-h^mostatic  Lever  Angiotribe 
Downes'  Sterilizable  Cable  to  Storage  Battery 
DowNEs'  Electro-h^mostatic  Angiotribe     . 


457 

4.57 

457 

465 

467 

469 

469 

469 

470 

470 

470 

471 

472 

473 

474 

476 

477 

477 

478 

478 

479 

479 

480 

481 

481 

481 

482 

482 

483 

483 

484 

485 

485 

485 

416 

486 

487 

487 

488 

489 

490 

490 

491 

491 

495 

495 

496 

496 

497 

498 

499 


LIST  OF  JLLUSTMATIONS. 


FIG.  TACK 

352.  Electro-ii^mostasis  Angiotribes  with  Bl.^des     ....  499 

353.  DowNEs'  .Shield 500 

354.  DowNES'  Electro-thermic  Cautery  Knii'e   .....  501 

355.  Ditto,  applied  to  Ovarian  Cystoma  (Jacob:,)       ....  502 

356.  Electro-Hjsmostasis  in  Pan-IIystkrecto.my  (Jacobs)     .         .         .  503 

357.  Ditto 504 

358.  Showing  Continuous  Incision  (Howard  Kelly)       ....  506 

359.  Tumour  connected  only  by  Uound  Ligament  and  Right  Adnexa  507 

360.  Sagittal  Section  of  Large  Myomatous  Tumour  (Howard  Kelly)  508 

361.  Ditto 508 

362.  Zweifel's  Angiotribe  .........  510 

3G3.  Ligature  of  Ovarian.  Eocnd  Ligament,  and  Uterine  Arteries 

(Xoble)       . .511 

364.  Ditto  ............  511 

365.  Tumour  with  Omental  Adhesions  (Howard  Kelly)        .         .         -  512 

366.  Necrosed  3Iass  passed  through  Os  Uteri   .....  513 

367.  Preliminary  Incision  round  Cervix     ......  516 

3(18,  369,  370.  Claw  Forceps 516 

371.  O'Sullivan's  Uterine  Tractor 517 

372.  Detachment  of  the  Bladder       .....-•  517 

373.  Martin's  Eetractor     .........  518 

374.  Martin's  Large  Retractor          .......  518 

375.  Martin's  Large  Perineal  Retractor  ......  51S 

376.  Lateral  Retractor     .         .         .         .         .         .         .         .         .519 

377.  Olshausen's  Needle-holder          .......  519 

378.  Martin's  Xeedle-holder      ........  520 

379.  Schauta's  Xeedle-holder     ........  520 

380.  Fenestrated  Retractor 520 

381.  Olshausen's  Retractor         ........  521 

382.  Division  of  Anterior  Wall  of  Uterus        .....  521 

383.  384.  Useful  Blunt-pointed  Broad  Ligament  Scissors           .          .  522 

385.  Patient's  Position  in  Pryok's  Vaginal  Pan-Hysterectomy          .  523 

386.  Uterus     and     Adnexa     removed    by    Pryor's     Vaginal    Pan- 

hysterectomy   ..........  524 

387.  Ehkenfest's  Ligature  Tightener          ......  525 

388.  Doyen's  Lever  Pince •  527 

389.  Same,  open  as  Forceps          ........  527 

390.  Uterus  drawn  down  (Doyen)        .         .          .          .         ...          •  528 

391.  Pressure  Forceps  applied  to  Left  Broad  Ligament  (Doyen)      .  528 

392.  Pressure  Forceps  applied  to  Right  Broad  Ligament  (Doyen)    .  528 

393.  Pressure  Forceps  applied  from  above  (Doyen)    ....  528 

394.  Drawing  down  the  Uterus  afteu  Completion  of  Section  (Doyen)  529 
.395.  Doyen's  Large  Clamp  Forceps 531 

396.  Application  of  Clamp  to  Broad  Ligament          ;         .         .         .  531 

397.  Application  of  Two  Clamps 532 

398.  Temperature  Chart     . •         •  541 

399.  Zweifel's  Needle 547 

400.  Section  of  Scirrhus  and  Adenoid  Portion  (Mary  Dixon  Jones)   .  557 

401.  Adenoid  and  Medullary:  Portion  (Mary  Dixon  Jones)          .         .  557 

402.  Thrombosis  of  Lymph  Vessel  (IMary  Dixon  Jones)          .         .          .  557 

403.  Adeno-Carctnoma  of  the  Cervix  (Howard  Kelly)          .         .         •  559 


LIST   OF  ILLUSTRATIONS. 


riG.  PAGE 

404.  Section  of  Growth  kemoved  by  Curette  (Authorj      .         .         .  560 

405.  Ditto  (Author) 561 

406.  Sections    showing    Glandular    Alveoli    lined   with    Columnar 

Epithelium         ..........  561 

407.  Carcinoma  Psammosum  (Schmit)   .......  564 

408.  Surface  of  Cervix,  showing  Epithelial  Ingrowing  (Author)       .  565 

409.  True  "  Nest  " ■  .  565 

410.  Fasciculated  Connected  Tissue  (same  specimen)          .         •         .  566 

411.  Cancer  eating  away  Lower  Half  op  the  Uterus  (R.  Barnes)    .  568 

412.  Double  Hydro-ureter  due  to  Advanced  Cancer  of  the  Uterus 

(Howard  Kelly) 569 

413.  Cancer  of  the  Body  of  the  Uterus  (Eiige  and  Veit)  .         .         .  573 

414.  Cakcinoma  of  the  Cervix  (Jessett)       ......  573 

415.  Carcinojia  of  the  Body  of  the  Uterus  (Jessett)          .         .          .  574 

416.  Cervix  held  by  Short  Silk  Sutures  (Howaril  Kelly)  .          .          .  591 

417.  Anterior  Incision  across  the  Cervix  (Howard  Kelly)           .         .  59'2 

418.  Pieces    op    Cancerous     Uterus    extirpated    by     Quadrisection 

(Howard  Kelly) 593 

410.  Separation  op  tHe  Bladder  from  the  Cervix  (Howard  Kelly)     .  595 

420.  Detachment  by  Scissors  of  YAGI^^AL  Collarette  (Doyen)   .          .  ■  595 

421.  Uterus    removed    by   Bumm's   Practical    Abdominal    Operation 

(Franz) .  .  .598 

422.  View  op  Carcinoma  from  the  Same  Uterus  (seen  from  below)  599 

423.  Posterior  Cul-de-sac  opened  (A.  Martin)      .....  602 

424.  Suturing   the    Lateral    Structures    in    the    Pelvic    Floor   (A. 

Martin) 603 

425.  Chorion-epithelioma  (Haultaiu)   .......  605 

426.  Ovum  of  a  Guinea- Pig 608 

427.  Section  of  Deciduoma  Malignum  froji  the  Corpus  Uteri  .         .  609 

428.  Portion  of  Villus,  showing  the  Origin  of  the  Tumour  from  the 

Epithelium  (Teacher)       .         .         .         .         .         .         .         .  610 

429.  Vacuolated     Syncytium     with     Masses    of    Langhan's    Larger 

Elements  embedded  (Teacher)           ......  611 

430.  Cell  Mass,  showing  Large  Decidua  Cell-like  Elements  (Teacher)  612 

431.  Typical  Mass  of  Chorion-epithelioma  (Teacher)  .         .         .613 

432.  Necrotic  Area,  Cellular  Area  op  Activity,  and  A'illi  (Haultain)  614 

433.  Area  op  Invasion  (Haultain)        .         .         .         .         .         .         .  614 

434.  Branching  Multinucleated  Protoplasmic  Processes  (Haultain)  .  615 

435.  Isolated   Mass   op   Syncytium   in  Blood-vessel  of   Uterus  (Von 

Spee)         .         .         .         .         ...         .         .         .         .         .616 

436.  Tubercular  Disease  op  the  Uterus  (Robert  Barnes)    .         .         .  .632 

437.  Tuberculosis  op  the  Cervix  (After  Cornil)            ....  633 

438.  Experimental  Tuberculosis  (Cornil)    ......  634 

439.  Uterus,   Tubes,   Broad   Ligaments   and    Ovaries    studded    avith 

Tubercles  (Howard  Kelly)         .......  634 

410.  Tubal  Tuberculosis  (Murphy)      .         .         .         .         .         .         .  637 

441.  Tubercle  op  the  Fallopian  Tube  (CuUingworth)         .          .         .  637 

442.  Tubercular  Salpingitis  (CuUingworth)         .       '  .         .         .         .  638 

443.  Tubercular  Left  Tube  with  Adherent  Omentum  (Howard  Kelly)  639 

444.  Tuberculosis  op  the  Tubes  (Murphy)  ......  640 

445.  Tuberculosis  op  the  Tube  (Kelly)       .         .         .         .          .         .  643 


LIST  OF  TLLUSTRATrONS. 


FIG. 

44G.  TuBKRCULAU  TuBo-OvARiAX  Abscess  (Murphy) 

447.  C'HKONIC    PAliKXCHYMATuUS   HVPERTRfiPHIC    SaLI'IXGITIS      . 

448.  Normal  Fallopian'  Tcbk  in  Section  Qlacalister) 

449.  Ck)MPLKTE  Obstkcctiqx  uf  the  Ostioi  (Alban  Doran)  . 

450.  Ovary  and   Tcbe   showing   Obstbcctiox    of   the   Ostiuji  (-A-lban 

Doran)       .......  .  . 

451.  OsTiuii  op  Normal  Fallopian  Tcbi:     ..... 

452.  Tcbo-ovarian  Ctst  from  the  Eight  Side  (Howarfl  Kelly)    . 

453.  TcBO-ovARiAN  Cyst  laid  open  (Howard  Kelly) 

454.  HAEMORRHAGE    INTO  FaLLOPIAN  TcBE   NOT  DUE  TO  ECTOPIC    Ge.STATION 

(Alban  Doran)   ......... 

455.  HjiMORRHAGE   INTO   UtERINE   CavITY   AND    FaLLOPIAN    TuBE   XoT  DLE 

TO  Ectopic  Gestation  (Griffiths)       ..... 

4.56.  Ovaries:  Mesooietria  and  Fallopian  Tubes  tiewed  from  behind 

(Author)    .......... 

457.  Hydro-Salpinx  Simplex  with  Right  Cystic  Ovary  attached 

458.  SPECiiiENS  of  Accessory  Fallopian  Tubes  (S.  Handley) 

459.  Left  Uterine  Appendages  with  the   Cysts  in  the  Free   Ed^e 

of  the  Broad  Ligament  (Author)     ..... 

460.  Section  of  Wall  of  Upper  Cyst  showing  the  Plic^  (S.  Handley) 

461.  Plics!  fused  at  the  Tips     ....... 

462.  Cystic  and  Sclerosed   Ovary    with   Accessory  Tube   Cysts  and 

Hydrosalpinx  ......... 

463.  Left  Ovarian  Cyst  with  Twisted  Pedicle 

464.  Inparcted  Hydatid  with  constricted  Pedicle  (Howard  Kelly) 
46.5.  Section  of  Fallopian  Tube  removed  for  Pyo-salpinx 

466.  Primary  Carcuxoma  of  Fallopian  Tube  (Hubert  Pioberts)    . 

467.  PRI3IARY  Papilloma  op  Fallopian  Tube  (Hubert  Eoberts)     . 

468.  Primary  Carcinoma  of  Fallopian  Tube  ^Hubert  Eoberts)     . 

469.  Salpingocele  (after  Segars)  ...... 

470.  Adhesions   of    the   Outer   Free   Extremities  of    both   Uterine 

Tubes  tii  the  Ovaries  (Howard  Kelly)       .... 

471.  Adhesion^s    of    Ovary-,    Tubes,    Appendix,    and    C^cum    (Howard 

Kelly) 

472.  Extra-Uterine  Pregnancy  (Howard  Kelly)  .... 

473.  Lithopedion    removed    from    the    Abdominal    Cavity    (Howard 

Kelly) 

474.  Tubal  ^Iole  (after  Walter) 

475.  Uterine    Decidua    expelled    in   a    Case    of    Tubal    Pregx'ax'cy 

(after  Bland -Sutton)   ........ 

476.  Case  op  Tubal  Pregnancy  in  which  the  Fallopian  Tubes  were 

atrophied  (Taylor)    .         . 

477.  Tubal  Abortion,  showing  the  Distended  Cavity  (Howard  Kelly) 

478.  Ectopic     Gestation,    sHOw^NG    Dilated    and    Thickened    Tubk 

(Howard  Kelly) 

479.  H.s:matocele  Capscle  seen"  from  within  (Taylor) 

480.  Left  Ectopic  Gestation  (Howard  Kelly)      .... 

481.  Broad  Ligament  Pregnancy  (Taylor)  ..... 

482.  Ectopic    Gestation,  iTcbo-uterine    or    Interstitial    Pregnancy 

(Taylor) 

483.  CoRNUAL  Pregnancy  (Rudolph  Smith  and  Herbert  Williamson) 


PACK 

643 
649 
650 
654 

654 
6.^5 
6.59 
060 

663 

663 

665 
667 
668 

671 
671 
672 

673 
674 
675 
676 
679 
680 
681 
68ii 

686 

687 
694 

695 
698 

698 

699 

700 

701 
702 
702 
703 

705 
706 


LIST   OF  ILLUSTRATIONS. 


Ovary  ax 


riG. 

484.  Double  Uterus  and  Vagina  (Taylor)  . 

485.  Chronic  Cortical  Ovaritis  (Bonnet  and  Petit) 

486.  Section  of  Normal  Ovary  (Macalister) 

487.  Ova  in  a  High  Degree  of  Colloid  Degeneration  (Mary  Dixon 

Jones)       .......... 

488.  Normal  Graafian  Follicle  with  Ovum  (Mary  Dixon  Jones) 

489.  Combined    Fatty   and    Colloid   Degeneration    of    Ovum  (Mary 

Dixon  Jones)     ........ 

490.  Colloid  Degeneration  of  the  Ovary  (Mary  Dixon  Jones) 

491.  Apoplexy  of  the  Ovaey  (Doran)  .... 

492.  Leiter's  Irrigator 

493.  Leiter's  Irrigator  applied  ..... 

494.  Condition  of  Internal  Female  Genitalia  in  Child  Twenty-Two 

Months  old  (G.  Carpenter) 

495.  Ovarian  Tumour  and  Fallopian  Tube  as  appearing  on  Eemoval 

(G.  Carpenter)   ...... 

496.  Condition    of    Adnexa    determined    by    Vaginal     and    Kectal 

Examination     ........ 

497.  Same  Adnexa  examined  Twenty-Seven  Days  afterwards 

498.  Portion  of  Multilocular  Ovarian  Cyst  (Bland- Sutton) 

499.  Ovarian  Dermoid   with    Spurious   Mamma    and    Nipple    (Bland 

Sutton) 

500.  Incipient  Oophoronic  Cyst  (Bland-Sutton)   . 

501.  Cyst  of  the  Parovarian,  showing  its  Eelation  to 

Tube  (Bland-Sutton) 

502.  Parovarian  Cyst  (Howard  Kelly) 

503.  Cysto-papilloma  of  the  Ovary  (Cullen) 

504.  Papillary  Ovarian  Cystoma  (Author) 

505.  Ovarian  Tumour  compressing  Thorax  (Spencer  Wells) 

506.  Ovarian  Cystoma  (Bright) 

507.  Large  Polycystic  Ovarian  Tumour     . 

508.  Paunched  Abdomen  closely  resembling  Ovarian  Cyst 

509.  Vertical  Outlines  of  a  Myomatous  Uterus 

510.  Nodular  Outlines  of  Large  Fibrocystic  Tumour 

511.  Solid  Multilocular  Ovarian  Cysto-Sarcoma  (Author) 

512.  Dull  Areas  in  Ovarian  Tumour  and  Ascites  (Barnes) 

512a.  Catch  with  Weight  for  holding  the  Peritoreal  Edges  open 

513.  Fibroma  of  both  Ovaries  (Cullingwortli)     .... 

514.  Microscopical  Section  op  Fibromatous  Tumour  of  Ovary  (Author) 

515.  Ditto  (Author) 

516.  Myoma  of  the  Ovary  (Doran)      .     -     . 

517.  Sarcoma  op  the  Ovary  (Doran)  . 

518.  Primary  Carcinoma  op  the  Ovary  (Author) 

519.  Primary  Carcinoma  of  the  Ovary — Scirrhus  (Targett) 

520.  Endothelioma  of  the  Ovary  (Ludwig  Pick") 

521.  Incisions  of  Sanger  and  Zuckerkandl  for  Perineotomy 

522.  Examining  Cyst  Wall  for  Adhesions  (Spencer  Wells) 

523.  Modification  of  Wells'  Trocar  .         .       -. 

524.  Nelaton's  Forceps  for  seizing  Wall  of  Cyst 

525.  526.  Tait's  Syphon  Trocars  ..... 
527   Insertion  op  Trocar  into  Cyst  (Spencer  Wells)  . 


LTST   OF  ILLUSTRATIONS. 


PAGE 

794 
795 
796 
803 
803 
806 
808 
809 


ier) 


(Emery 


528.  Drawing  the  Cyst  out  of  Inoibion  (Spencer  Wells) 

529.  Graspixg  Sulib  Tuabectjlai;  Tumour  (Spencer  Wells) 

530.  Aspirating  Sucker 

531.  Pseudo-Hermaphrodisji  with  Perineo-Sorotal  Hypospadias 

532.  Ditto  (Zweifel) 

533.  P.SEUDO-HERMAPHRODISJI  (Arthur  Maude) 

534.  Coxgkxital  ^Malformation  of  the  Vulva  (Author) 

535.  Epithelioma  of  the  Clitoris  (0.  Noble)       .         .         .         , 
535a.  Carcinoma  op  the  Vulya  (Noble)       ....         (facing)  810 
535b.  Diffuse  Papillary  Epithelioma  of  the  Clitoris  (Mangio'alli) 

( facing)  812 

536.  VuLVo- Vaginal  Hernia  (Winckel) 

537.  Abscess  of  the  Bartholiniax  Glaxd  ^Hu; 

538.  Vegetation  of  the  Vulva  (Tarnier)    . 

539.  Elephantiasis  Vulv^  (Author)    . 

540.  Elephantiasis  Vulvae  (Halliday  Croom) 

541.  Elephantiasis  Vulv^  (Pozzi) 

542.  Solid  Glass  Dilator  and  Rest  of  Author 

543.  Uterus  Duplex — Left-Sided  H^matometea  with  Ovary 

Marvel) . 

544.  DiDELPHiAN  Uterus,  Vagina  divided  by  Partial  Septum  (Oliver) 

545.  Uterus  Didelphys  (A.  Giles)        ..... 

546.  H.SMATO-COLPOS,  from  Atresia  of  the  Vagina  (Pozzi) 

547.  Absent  Vagina  with  Atresia  op  the  Uterus  (Legend) 

548.  Spindle-celled  Sarcoma  op  the  Vagina  (Author) 

549.  Sarcoma  op  the  Vagina  (H.  .Jellett)     .... 

550.  Diagrammatic  Representation  of  Different  Varieties  of  Fistula 

(After  Sinety)    ........ 

551.  Genital  Fistula         ....... 

552.  Genital  Fistula;  (Bozeman)         ..... 

553.  Incarceration  of  Cekvis  Uteri  in  Bladder  (Bozeman) 

554.  Incarceration  of  Cervix  Uteri  in  Rectum  (Bozeman) 

555.  Vesico- Vaginal  Fistula  Needles         .... 

556.  Bryant's  Needles        ....... 

557.  Emmet's  Lance-headed  Needles  .... 

558.  Vesico-Vaginal  Fistula  Knives 

559.  Wire  Carrier 

560.  Rake  for  holding  back  Flaps 

561.  WnjE-CATCH 

562.  Wibe-twister 

563.  Bozeman's  Adjusters   .  . 

564.  Showing  Button  Suture  closing  Fistula  (Bozeman) 

565.  Treatment  op  Vesico-Vaginal  Fistula  by  Supra-Pubic  In( 

(Howard  Kelly)  .... 

566.  Operation  completed  (Howard  Kelly)  . 

567.  Dilator  in  Position    .... 

568.  Utero-Vesical  Drainage  Support 

569.  570.  To  illustrate  Detachment  of  the  Bladder  above  and  its 

Attachment  to  the  Uterus  below  (Howard  Kelly) 

571.  Prolapse  op  the  Urethra  (Arnold  Lea) 

572.  Urethral  Caruncle     ...... 


815 
827 
828 
831 
831 
832 
841 

850 
851 
852 
853 
855 
867 
868 

869 
869 
870 
870 
870 
872 
872 
873 
873 
873 
874 
875 
875 
876 
876 

878 
879 
880 
880 

881 
885 
890 


LIST   OF  ILLUSTRATIONS. 


573.  BtTTTON-HOLE    SciSSOBS 

574.  Emmet's  Button-hole  Opening     .... 

575.  Koltscher's  Diagnostic  and  Operative  Cystoscope 

576.  Dorsal    Position    foe   Exploration    of    Bladder   and    Ureters 

(Howard  Kelly) 

577.  Patient  supported  with  Kelly's  Suspenders 

578.  Kelly's  Urethral  Calibator       .         .         .  , 

579.  Speculum  and  Obturator    ..... 

580.  No  6.  Speculum 

581.  Howard  Kelly's  Sucker      ..... 

582.  Showing  the  Use  of  Ureteral  Searcher    . 

583.  Method  of  Opening  the  Bladder  (Howard  Kelly) 

584.  Hairpin  Calculus  (Howard  Kelly) 

585.  Metal   Penholder   removed  from  Bladder  of  Patient  (Tenisoa 

Collins)     ........ 

586.  Groom's  Procedure  for  Kemoval  op  S.uall  Calculi 

587.  Mixed  Cell  Sarcoma  of  the  Bladder  (Author)  . 

588.  589.  Thompson's  Forceps  for  Eemoval  op  Tumour  from  Bladder 

590.  Diagnosis  op  Split  and  Double  Ureter      .... 

591.  Kidney  with  Double  Pelvis  and  Double  Ureters 

592.  Irrigation  op  the  Ureter  (Howard  Kelly)  .... 

593.  Ureteral  Catheter  with  Eeduced  Handle  (Howard  Kelly) 

594.  Ureteral  Catheters  without  Handles  (Howard  Kelly) 

595.  Toothed  Forceps  (Howard  Kelly)  ..... 

596.  Urine  Collector  (Howard  Kelly)  ..... 

597.  Ureteral  Searcher  (Howard  Kelly)     ..... 

598.  Hard  Ureteral  Catheters  (Howard  Kelly) 

599.  Hard  Eubber  Bougies  introduced  into  both  Ureters 

600.  Stricture  op  Eight  Ureter  demonstrated  by  Catheterization 

601.  Section  showing  Ureter  held  by  Forceps  .... 

602.  The  Field  of  Operation  through  the  Superior  Strait 

603.  Uretero-ureteral  Anastomosis    ...... 

604.  Ureteral  Guide  (Howard  Kelly)  ..... 

605.  Horse-shoe    Kidney    with    Transposition    op    Large    VasOular 

Trunks     ........... 

600.  Author's  Belt  for  Movable  Kidney  ...... 

607.  Phosphatic  Calculus  removed  from  Eight  Kidney 

608.  Branched  Calculos  forming  a  Cast  op  the  Pelvis  and  Calyces 

OP  THE  Kidney  (P.  J.  Freyer)    ....... 

609.  Degenerated  Kidney,  the  Eesult  of  Pyelo-nephritis  (C.  Noble) 
0.0.  Examination  op  the  Eectum  with  Proctoscope  (Howard  Kelly)  . 

611.  Proctoscope  of  Strauss 

612.  Showing  the  Passage  of  the  Instrument 

613.  Eectal  Director  and  Probe 

614.  Straight  (Spring  Pile  Scissors) 

615.  Pile  Fork 

616.  Pile  Scissors  bent  on  the  Flat 

617.  Catch  Pile  Forceps  . 

618.  Pile  Forceps   .... 

619.  Pollock's  Clamp  for  crushing  Hemorrhoids 

620.  Eectal  Bougies,  Conical  and  Bulbous 


I'AGE 

893 
893 

896 

807 
897 
898 
899 
900 
900 
901 
909 
912 

912 
914 
916 
918 
921 
921 
■  925 
930 
930 
930 
930 
931) 
930 
931 
931 
936 
937 
940 
941 

947 
959 
962 

963 
963 
966 
.967 
970 
972 
976 
976 
976 
976 

,  976 
978 

,  980 


LIST  OF  ILLUSTRATION.^. 


FIG, 

C21.  Author's  Rectal  Positor  ..... 

622.  Introitus  draytn  before  Ablation  of  the  IfyMKN  ix 

Tex  Years  married         ..... 

623.  Showino  the  Elkctrodk  in  the  Uteuink  Cavm  v 
(;24.  Faradic  Current  Battery  .... 
025,  626.  Bipolar  Intra-iterine  Excitors 

627.  Concentric  JIipolar  ...... 

628.  Bipolar  Vaginal        ...... 

629.  Ditto 

630.  Electrode  for  Galvanu-chkmioal  Cauterization 

631.  Gas-carbon  Electrode        ..... 
6.S2.  Tlatinum-ended  Sounds  with  Flexible  Ste.m.^  . 

633.  Rigid  Platinum  Sound       ..... 

634.  Application  op  Vibration  Treatment 
(;35.  Electrical  Motor  and  Cable  with  Steji 
(!36.  Electrical  Hand  Vibrator        .... 
637.  A  FEW  Concuteurs     ...... 


A   Patient 


987 

991 
1002 
1003 

1003 
1003 
1004 
1004 
1004 
1004 
1004 
1005 
1015 
lOli; 

I  ok; 

1M!7 


LIST    OF    PLATES 


I'LATE  iQ   FACE   PACK 

^4.     Section    op    the    Mature    Ovary,  illustrating    the    Various 
Stages  in  the  Development  and  Regression  of  the  Graafian 

Follicles 28 

B.    Human  Ovum  ..........  29 

I.     Appendix,  Fallopian  Tube  and  Cystic  Ovary.    (Author.)        .  42 
II.     An    Ovarian   Cyst   with    Omental   Adhesions   above   and  an 

Adherent  Vermiform  Appendix  below.     (Kelly.)  .         .  42 

III.  Carcinoma  of  a  Large  Mobile  Kidney.     (Author.)  .         ,  44 

IV.  The  same  Kidney  shown  in  Section.     (Author.)        ...  45 
Section  from  Carcinomatous  Area.    (Targett.)         ...  45 

V.    Fibro-adenoma  of  the  Ovary  occurring  with  a  Fibromyom.^tous 

Uterus.    (Author.) 62 

To  show  Lobulated  External  Surface  of  the  Tumour  .         .       62 
YI.     Fibromyomatous  Uterus  removed  from  the  same  Patient  prom 
whom    the     Ovary    (Plate    V.)    was    taken.      Eecovery. 
(Author.)        ..........       63 

VII.     Operating  Theatre  (St.  Eonans') 110 

VIII.     Another  View  of  same  Theatre      .         .  .  .  .         .111 

IX.    Patient   prepared   for   Operation  ......     128 

Same  in  Partial  Trendelenburg  Position        ....     128 

X.     Streptococcus     Pyogenes  —  Gonococcus    (Neisser)  —  Staphylo- 
coccus Pyogenes — B.  Coli  Communis — B.  Tuberculosis  .     137 
XI.     A.  Showing  the  Closure  of  the  Abdominal  Wound.    (Author.)    170 
B.  Closure    of    the    Fascia    by    Mattress    Suture,   after    C. 
Noble's  Method  .........     170 

XII.  Showing  the  Wound  in  the  Rectus  closed  with  Continuous 
Catgut  Suture  ;  Closure  of  the  Aponeurosis  by  superim- 
posing the  Eight  Aponeurosis  upon  the  Left  and  Suturing 
it    with    Special    Form    of    Continuous    Catgut     Suture 

(Noble.)  . 171 

Showing    Closure    of    Peritoneum    with    Continuous    Catgut 
Suture  ;  the  Borders  of  the  (Divided)  Rectus  Muscle  ;  the 
Left  Aponeurosis  freed  prom  the  Layer  of  Fat  ;  the  Eight 
Aponeurosis   separated   from    the   Eectus  Muscle  and  re- 
flected.    (Noble.)         .         .         .         .         .         .         .         .171 

XIII.     Uterus  GBA^-ID.     Third  Month.     (Bumm.)       ....      173 

XIIIa.  Vasomotor  Coloration  of   'Face  with  Pigmentary    Changes 

ASSOCIATED   WITH    TlOLENT    DySMENORRHCEA    AND    OOPHORALGIA. 

(Author.) 188 


LLST  OF  PLATES. 


PLATE  TO   FACE 

XIV.     Case  I.  Fibkomatods  Uterus  removed  by  Vaginal  Hyste- 
rectomy FOR  Prolapse  op  15  years'   standing,  showing 
Adhesions — Return  of  the  Bladder  into  the  Pelvic 
Cavity.     (Author.)  ....... 

XV.     Case  II.    Senile  Atrophic  Uterus  removed  from  Proci- 
DENT   Sao    after  the    Eeturn    op    the    Bladder    and 
Rectum  into  the  Pelvic  Cavity,  in  a  Patient  aged  74. 
(Author.)        ......... 

XVI.     Case  I.    Sectional  Drawin6,,showing  Extent  of  Adhesions 
to  the  Bladder  ........ 

XVII.     Case  II.     Sectional  Drawing,  showing  Extent  of  Adhe- 
sions OP  the  Sac  Wall,  Bladder,  and  Rectum 
XVIII.     Curettings    from  a   Case  of  Glandular    Endometritis. 
(Author.)        .  . 

XIX.     Portion   of   Curettings   taken   from   a    Case    of    Endo- 
metritis with  Follicular  Degeneration  of  the  Cervix 
AND  Erosion.     (Author.)  ...... 

XIXa.    Drawings    of    the    Ovaries    and    Photograph    of    the 
Uterus  with  Adnexa.     (Author.)  ..... 

XX.     Transverse   Section  of   One  Half  op  the   Portio   in   a 
Case  of  Severe  Erosion  and  Cystic  Degeneration  op 
THE  Cervical  Mucosa.    (Author.)''.         .... 

XXI.     Curettings    of     Glandular    Endometritis— taken    fr(jm 
SAME  Case.     (Author.)    .         .  .         .         .         . 

XXII.     Section    from    a    Deep    Erosion   of    the   Cervix   Uteri, 

ASSOCIATED    WITH    GLANDULAR    ENDOMETRITIS.       (Author.)    . 

XXIII.  Curettings  from   a  Case  op  Endometritis  due  to  Gono- 

coccus.     (Author.)  ....... 

XXIV.  Section  op  an   Adenomyomatous  Cervix,  taken   from  ax 

Eroded  Surface.     (Author.) 
XXV.     Portion  of  Central  Cavity.     (Author.)  . 
XXVa.     a  Section  from  close  to  Centre.     (Author.) 
XXVb.     a  Section  from  close  to  Centre     (Author.) 
XXVII.    Placental  Polypus.     (Bumm.) 
XXVIII.     Giant  Multiple  Myoma.     (Author.) 
XXIX.     Posterior  Surface  op  same  Tumour.     (Author.) 
■XXX.     Dual  Myoma   op  the   Uterus — Necrobiosis  and  ilucoiD 

WITH  Calcareous  Degeneration.     (Author.)  . 
XXXI.     Large  Multiple  Myoma  removed  from  Patient,  aged  54, 
suffering  from  Profound  An^emia  caused  by  A^iolent 
h.ffi;morrhage    during    the    climacteric   supra-vagixal 
Hysterectomy.     (Author.)      ...... 

XXXII.     Cysto-sarcoma  of   the   Uterus,  with   Associated   Necro- 
BiOTic   AND   Mucoid  Degeneration   surrounded  by  the 
Muscular  Structure  op  the  Uterus.    (W.  B.  Jessett.) 
XXXIII.     Subserous  Fibroid  of  Uterus  with  Myxomatous  Degenera- 
tion.    (Author.)     ........ 

XXXIV.     Telangiectatic  Myoma.     (Purefoy.)     '      .         .         .         . 

XXXV.  Section  op  Portion  of  Myoma,  showing  Central  area  of 
Calcification,  the  Result  of  Hyaline  Degeneration. 
(Author.)        .         .         .      "  . 


308 

308 
30n 
309 
334 

334 
337 

352 
352 
353 
353 


354 
854 
354 
355 
392 
402 
408 

410 


412 


413 


418 

414 


415 


LIST   or   PLATES. 


I'LATE  TO   FACE    I'AGK 

XXXVI.     Area     ok     Hyaline     Ukgeneuatiun,     with     I'uucess     of 

Calcification  I'RociiKDixG      ......     415 

XXXAII.     Laiigk  Ixtramvual   Myoma  op  the    Uterus,  showing  ^ith 
Reticulated    Structure    removed    by    Supra-vaginal 

Hysterectomy.     (Author.) 420 

XXXVIII.     Uterine  Myoma  with  Embedded  Mulitplk  Nuclei  removed 
AT   THE  Climacteric  «y  Supra-vaginal    Hysterectomy. 

(Author) 427 

XXXIX.     (iiANT  Fibromyojia.     (Author.) 446 

XL.     Multiple    Myoma,    showing    Encapsuled    Nuclei,    in    a 
Patient  aged  .55.  aftei:    Two  Attacks   of   Teritonitis. 

(Author.) 447 

XLI.  Large  Dense  Fibroma,  of  Stony  Hardness,  filling  the 
1'elvic  I'avity.  and  fixed  by-  Adhesions  to  the  Rectum 
AND  Floor  of  the  Pelvis.  (Author.)  ....  458 
XLII.  My'oma  complicated  with  Carcinoma.  (Author.)  .  .  570 
XLIII.  Cancer  of  the  Fundus — Cervic  free  from  Disease — 
Uterus  and  Adnexa  removed  by  Bumm's  r)pERATiON. 
(Author.)         .........     572 

XLIV.       CURETTINGS   FROM    FuNDUS   REMOVED   BEFORE   OPERATION  .       .573 

XL^'.  Section  of  Uterus  at  End  of  the  Third  Month  of 
Pregnancy  with  Carcinom.4.tous  Cervix,  showing  Decidua 
AND  Ruptured  Amnion.  Operation  Vagikal  Hysterec- 
tomy.    (Bumm.) 600 

XLVL,  XLYIa.     Chorionepitheliomatous  Tumour  with  Cystic  Cavity 

(Croom.)  ......  (between)  616-617 

XLVII.     Metastatic  Deposits  in  the  Lung.     (Croom.)  (between)  616-617 
XLYIII.    Prim.\ry    Tuberculosis    of    the    Fallopian    'J'ube — Pyo- 

.-ALPiNX.     (Author.)  .......     641 

Same  Sac  opened  from  behind  .  .  .  .         .641 

XLIX.     Adnexa,  showing  Section  of  the  Dilated  Tube  and  the 
Contained     Blood     Coagulum  ;      also     the     Adherent 

Fimbria.    (Author.) 642 

Same   Specimen,  showing  the   Ovary   cut   open    and   the 

RECENT  CORPU.>  LUTEUM.   (AuthoT.)      ....   642 

L.     Primary  Tuberculosis  of  Fallopian  Tube.     (Author.)      .  643 

LI.     Acute  Tuberculosis  of  Fallopian  Tube.     (.L  Stevenson.)  643 

LII.     Section  of  the  Tube.     (Author.)       .....  648 

LIII.     Chronic  Hypertrophic  Salpingitis.    (Author.)  .         .  649 

LH'.,  LY.     Transverse    Section  of   Fallopian   Tubes  exemplifying 

Hypertrophic  and  Desquamative  Salpingitis.  (Author.)  652 

LYI.,LYII.    Adnexal  Tumours.     (Author.) 654 

LYIII.     Left  Adnexa.     (Author.)  ......  655 

LIX.     Right  Adnexa.     (Author.) 655 

LX.    Posterior  Aspect  of  Mass,  whh  Apron  of  Exudation    .  655 

LXI.     True  Tubo-ovarian  Cyst.     (J.  Taylor.)      ....  658 

LXII.     Outer  Surface    of    the   Cyst,   with   the    Incorporated 

Fallopian  Tube    ........  659 

LXIII.     Nodular  Salpingitis.     (Author.)       .....  662 

LXIY.     Posterior  Surface  .......  667 

LXV.    Anterior  Surface  .......  667 


LIST   OF  PLATES. 


I'LATE  TO   FACE   PAGE 

LXVI.     Double  Pyo-salpinx.     (Author.) 676 

LXVII.    Double  Pyo-salpinx,  each  Large  Pus  Sac  communicating 

WITH  THE  Utekine  Cavity.     (T.  Gelstun  Atkins.)  .     677 

LXVIII.     Caecinoma  of  the  Fallopian  Tube.     (Author.)       .         .     678 
LXIX.     Carcinoma  of  the  Fallopian  Tube — Tumour  laid  open     679 
LXIXa,    Hydatid  Cyst  (Echinococcus)  of  the  Fallopian  Tube 

(T.  W.  Eden.) 682 

LXX.     Left  Intbaligamentaky  Gestation.     (Bumm.)        .         .     690 
LXXI.    Interstitial  Gestation  at  the  Fourth  Month.    (Bumm.)     691 
LXXII.     Ovarian  Gestation.     Eupturb  in  the  Sixth  Week.    (C. 

Van  Tusseubroek,  from  Bumm.)     .....     691 
LXXIII.     Unruptured   Tubal    Gestation    in    which    the   Embryo 
has  perished  during  the  Fourth  Week  from  Hemor- 
rhage INTO  the  Membranes.    (Mary  Scharlieb.)   .         .     699 
LXXIV.     Hematocele  Eetro-uterine — Tubal  Abortion.   (Bumm.)     700 
LXXV.     Instantaneous  Photograph  of  Eetro-uterine   Hemato- 
cele FROM  EUPTURE  OP  THE    FCETAL   SAO   IN  THE    ISTHMUS 

OF  THE  Left  Fallopian  Tube.     (Bumm.)   .         .         .     701 
LXXVI.     Eight  Peritubal  Hejiatocele  with  the  Outer  Surface 

OF  the  Wall  of  the  Sac.     (Author.)  .         .         .  .  710 

LXXVII.     Shows   the   Anterior   Wall  of   the   Sac  and   Ovarian 

Stroma,     (Author.) 710 

LXXVIII.  Gestation  Sac  with  Fcetus  ;  the  Upper  Cavity  shown 
IN  THE  Drawing  is  that  in  which  the  Septic  Fluid 

WAS  contained.     (Author.) 715 

LXXIX.     Ectopic  Gestation.    (Author.) 716 

LXXX.  Section  of  Cystic  Ovaritis  of  Ovary,  Sclerotic  and 
Cystic  Degeneration,  with  Thickened  Fallopian 
Tube  :  Fimbrie  Normal.  (Author.)  ....  718 
LXXXI.  Section  of  Hydrocystic  and  Sclerosed  Ovary — Adhesions 
on  the  Enlarged  Fallopian  Tube  and  Accessory 
OsTiA  WITH  Small  Pedunculated  Cyst  of  Morgagni. 

(Author.) 718 

LXXXII.     Ovaries,  showing  in  the  Eight  a  Cyst  with  Coagulum; 
IN    THE    Left,    Old    and    Eecent    Corpora    Lutea. 
(Author.)    .........     719 

LXXXIII.     BiLOCULAR  Cystic  Ovary  WITH  Fallopian  Tube.    (Author.)     719 
LXXXI  V.     Section  of  Ovary,  showing  Advanced  Stage  of  Sclerosis. 

(Author.)    .         .         .         ". 720 

LXXXV.  Section  from  Ovary  (Plate  LXXXIV.),  showing  Fibrous 
Formation  and  Minute  Cyst  Cavities  ;  a  Thickened 
Vessel  IS  seen  IN  THE  Field  near  the  Margin.  (Author.)  721 
^LXXXVI.  Macroscopical  Appearance  op  an  CEdematous  and 
Sclerosed  Ovary,  with  Thickened  Capsule  and  some 
Small  Cystic  Cavities  in  the  Cortex.  (Author.)  .  722 
LXXXVII.,  LXXXVIII.  Macroscopical  Appearances  of  Sclerosed 
AND    Cystic    Ovaries,    with    Nodular     Salpingitis. 

(Author.) - .  .  .  .722 

LXXXIX.  Photographs  of  Transverse  Sections  of  Sclerosed  and 
Cirrhotic  Ovaries,  in  which  there  has  been  Inter- 
stitial  Fibrosis  followed  by   Obliteration   of   the 


LIST  OF  plates;. 


72:-j 

723 

723 

723 

723 
726 
727 

728 


728 


I'LATE  TO  FACB   I'AGE 

Corpora  Lbtka  and  Follicles,  with  Cystic  Degenera- 
tion  ARISING   PROM   BOTH   OF   THE   LATTER.      (Author.) 

XC.     Section  of  Sclerosed  and  Cystic  Ovary.    (Author.) 
XCI.    Divided   Nodular   Fallopian    Tube,   removed   with    the 
same  Ovary.    (Author.)  ...... 

XOII.    Microscopical    Appearances,    1''rom    Centre    op    Section, 

h—b,  Plate  XC 

XCIII.    Microscopical  Appearances — Cortex  op  Plate  XC.  (u)  . 

XCIV.     Ovarian  Blood  Sao.    (Author.) 

XCV.     Interiok  op  same  Sac.     (Author.)      ..... 

XCVI.    Large  Eight  Ovarian  Pos  Sac  with  the  Portion  op  the 

Tube  opening  into  the  Sac.    (Author.) 
XCVII.    Smaller    Lept     Cystic     and    Gyromatous    Ovary    with 
Sclerosed    Capsule    with    the    Cystic    Tube   removed 
PROM  the  same  Patient.     (Author.)       .... 

XCVIII.     Pyo-cystic    Ovary    bisected;     removed    by    Abdominal 

Celiotomy.     (Author.)  .......     729 

XCIX.     External   Surface  op  same  Adnexa,  showing  the  Adhe- 
sions and  Incorporated  Tube        .....     72'J 

C.    Tubo-Ovakian   Pyo-cyst — Sac   opened   to   show   Interior 
— Tube  opening  into  the   Sac — Abdominal   Ccelxotomy. 

(Author.) 729 

CI.  External  Surface  op  the  Ovary — the  Adherent  Tube 

HAS   been   dissected   OUT   PROM    THE    BeD   OF   ADHESIONS      . 

CII.    Sections    op    Kesected    Portions    op    Ovaries    removed 

PROM    Patients   at   the  Same  Time  that  the  Uterus 

was  Ventro-suspended.     (Author.)  .... 

cm.    Macroscopical   Appearances  of  a  Cystic  anD|  Sclerosed 

Ovary  with  Portion  op  Tube.    (Author.) 
CIV.    First    Operation  :  —  Eight    Cystic    Ovary    removed    by 
Cceliotomy   prom    a    Patient    suffering   from    Severe 
Anorexia    and     Constant    Vomiting,    with    Complete 
Eelief  prom  the  Symptoms.    (Author.)  .... 

CV.  Second  Operation  : — The  Left  Ovary  containing  Blood 
Cyst  and  Dual  Cyst  in  the  Broad  Ligament  removed 
One  Year  subsequently  to  the    Previous  Operation, 

AND    FOR   similar   SYMPTOMS,    FROM    THE    SAME   PaTIENT 

CVI.    Third   Operation  :— Uterus   and    Broad   Ligament    Cyst 
OF  SAME  Patient,  from  which  the  Ovaries  (shown  in 
Plates    CIV.,    CV.)    were    removed  ;    Operation    Two 
Years  subsequently       ....... 

CVII.    Broad  Ligament  Cyst.    (J.  Taylor.)         .... 

CVIII.    Cyst  of  the  Meso-salpinx,  simulating  an  Ectopic  Gesta- 
tion Cyst.     (Author.)    .......     "'^^ 

CIX.    Parovarian   Cyst  lying  in  Douglas's  Pouch,  simulating 
Retroversion  on  Uterus.    (Author.)     .... 

ex.     Specimen   of   Double  Ovarian  Papillojia   and  Cervical 
Carcinoma,  with  Associated  Carcinoma  of  the  Cervix 
Uteri.     (Gelston  Atkins.)       ...... 

CXI.    Cysto-carcixoma  of  the  Ovary.    (Author.) 
CXII.     Interior  of  Cysto-carcinomatous  Ovary.     (Author.) 


729 

730 

731 

73G 
736 


737 
742 


43 


746 

748 
7411 


TJST  OF  PLATES. 


I'LATU 

OX  III. 


CXIV, 

cxv. 

CXVl. 
CXVII. 

CXVIII. 
OXIX. 

cxx. 

cxxr. 

OXXII. 


to  face  x'agb 
Solid    Ovarian    Adenoma    with    Oystoma,    removed    imme- 
diately AFTER   AN  AcUTE  ATTACK   OP  GeNEEAL  PeRITOHITIS. 

(Author.) 757 

Cysto-saecoma  op  the  Left  Ovary.     (Author.)    .         .         .  772 

Adeno-Fibroma  op  the  Ovary.     (Author.)  ....  774: 

Giant  Schirehus  Carcinoma  of  the  Ovary.     (Author.)        .  774 
Hydated     Cyst    connected    with     Eight     Ovary.     ((_'.     J. 

Cullingworth.)  ,          .          . 778 

Calculus  in  the  Eight  Kidney.     (Shenton.)         .         .         .  891: 

Calculus  in  the  Eight  Ureter.     (Shenton.)        .         .         .  894 

Two  Calculi  in  the  Bladder.     (Shenton.)            .          .         .  894 
Angioma  of  the  Liver  growing  from  the  Under  Surface 

OF  THE  Eight  Lobe.     (Author.) 954 

Sections  of  Angioma  of  the  Liver.     (Targett.)  .         .         .  955 


DISEASES  OF  WOMEN. 

CHAPTER   I. 

ANATOMICAL   AND    CLINICAL. 

Summary  of  Anatomical  Pacts  which  have  a  Bearing  on 
Gynsecological  Diagnosis  and  Practice. 

It  is  outside  the  seoi^e  of  this  work  to  enter  into  a  detailed 
description  of  the  female  pelvic  organs  and  their  relations.  There 
are  some  simple  anatomical  points  connected  with  the  female  organs 
of  generation  that  must,  however,  be  remembered  by  every  student 
and  practitioner,  and  which  have  an  important  clinical  bearing 
on  the  examination  and  conduct  of  a  gynaecological  case.  It  is 
necessary,  in  the  first  place,  very  briefly  to  allude  to  these. 

Vulva  (Fig.  1). — The  vulvar  orifice  is  elliptical  in  shape,  and 
comprises  the  mons  veneris,  labia  major  a,  labia  minora,  clitoris, 
meatus  urinarius,  vestibule,  fossa  navicularis,  fourchette,  and  hymen. 
It  varies  in  size  in  difierent  individuals.  In  some  women  the  vulvar 
opening  is  contracted.  Both  its  size  and  elliptical  shape  influence 
us  in  the  choice  and  method  of  introducing  a  speculum  in  the  virgin 
and  in  sensitive  women.  Occasionally  there  is  complete  atresia  of 
the  vaginal  orifice.  The  sebaceous  follicles  on  the  inner  surfaces  of 
the  labia,  with  the  adjacent  mucous  membrane,  ofier  to  all  contagious 
secretions  a  large  surface  for  the  retention  of  fluids,  septic  particles, 
or  any  specific  virus.  On  the  vulva  or  vulvar  orifice  we  occasion- 
ally find,  in  unhealthy  states  of  the  system,  aphthous  and  gangrenous 
sores,  specific  ulcers,  purulent  discharges ;  in  children,  noma  vulva?. 
Its  exposed  position  renders  it  specially  liable  to  injury,  either  from 
accident  or  violent  intercourse.  Owing  to  the  apposition  of  its 
mucous  surfaces,  the  irritation  produced  by  friction  during  exercise, 

B 


DISEASES   OF   WOMEN. 


or,  in  inflammatory  states  of  the  vagina,  by  unhealthy  discharges, 
causes  a  sense  of  heat,  and  other  symptoms  of  vulvitis.  During 
the  exanthemata,  ia  puerperal  and  other  fevers,  such  as  smallpox, 
measles  and  scarlatina,  the  vulva  is  occasionally  inflamed.  The 
predisposition  of  the  follicles  and  mucous  membrane  to  inflamma- 
tion, their  occasional  exposure  to  irritating  secretions,  the  effects 


Fig.  1. — The  Vulva*  (Shahpey). 

a,  Labia  majora;  h,  Labia  miuora;  c,  Meatus  urinarius;  d,  Glaus  clitoris; 
e,  Clitori.s ;  /,  Mons  veneris. 

of  uncleanliness  and  injuries,  and  the  abundance  of  cellular  tissue 
found  under  the  mucous  membrane,  afford  a  ready  explanation  of 
the  frequency  with  which  phlegmonous  inflammation  attacks  the 
vulva.     This  bulbus  vestibuli  with   its  erectile  tissue  corresponds 

*  Contrast  this  drawing  of  the  normal  virgin  outlet  with  that  of  the  relaxed 
vaginal  outlet  in  the  chapter  on  '  Euptured  Perinseum.' 


AXATOMfCAL    AXD    CLfXICAf..  S 

with  the  bulb  of  the  male  urethra.  Beneath  the  labia  is  the 
vascular  bulbus  hirudiniform  body,  the  bulb  of  Kobelt,  which  is 
composed  of  a  large  plexus  of  veins.  In  front  of  the  bulb  is 
another  smaller  plexus  at  each  side,  the  pars  intn-nvdia  of  Kobelt, 
corresponding  to  the  part  of  the  male  corpus  spongiosum  urethra) 
l)etween  the  bull)  and  the  glans.  In  this  anatomical  arrangemeuf 
we  have  an  explanation  of  pudendal  haemorrhage  and  thrombus. 
I  have  seen  fatal  haemorrhage  follow  from  malignant  ulceration  of 
one  labium,  notwithstanding  that  every  means  of  treatment  was 
employed.  The  large  vascular  supply  of  the  vulva  explains,  also, 
the  occurrence  of  septic  absorption  and  septicaemia,  which  result 
from  injuries  and  abscess  of  the  vulva,  or  from  the  breaking  down 
of  a  thrombus  and  the  exposure  of  coagula.  It  is  thus  evident 
that  cleanliness  is  the  first  essential  of  treatment  in  any  case  of 
vulvar  inflammation.  Careful  asepsis  is  indicated  when  any  in- 
cisions are  made  in  vulvitis.  The  vulvo-vaginal  gland  occasionally 
has  its  duct  occluded,  and  over-distension  of  the  duct  may  follow, 
with  arrest  of  secretion  and  inflammation  of  the  lining  membrane 
spreading  to  the  gland,  abscess  in  the  gland,  or  hyper-distension  of 
the  gland  and  the  formation  of  a  cyst.  The  presence  of  a  defined 
tumour  at  either  side  of  the  vulva,  painful  and  fluctuating,  varying 
in  size  from  a  large  nut  to  a  pigeon's  Qgg,  is  fairly  characteristic. 
The  analogy  of  the  labia  to  the  male  scrotum  is  obvious.  As  the 
loop  of  intestine  descends  with  the  spermatic  cord  in  the  male  into 
the  scrotum,  so  it  passes  with  the  round  ligament  to  the  labium  in 
the  female.  Care  must  be  taken  not  to  mistake  a  painful  hernia 
of  the  labium  for  an  abscess.  Unless  there  be  strangulation,  the 
hernia  returns  with  the  horizontal  posture  and  pressute.  The 
obliteration  of  the  canal  of  Xuck  explains  the  rarity  of  inguinal 
hernia  in  the  female  as  compared  with  the  male.  It  is  necessary  to 
bear  in  mind  the  contingency  of  a  hydrocele  of  the  round  ligament. 

A  lady  came  for  'removal  of  a  tumour.'  I  expressed  the  opinion  that  it 
was  a  hernia.  Another  surgeon  subsequently  pronounced  it  to  be  an  encysted 
hydrocele  of  the  left  round  ligament.  I  was,  in  the  course  of  time,  suddenly 
called  to  see  this  patient.  The  bowel  had  niptured.  I  made  an  artifici?] 
opening,  and  she  recovered.  Another  swelling  afterwards  came  in  the  right 
groin.  This  proved  to  be  a  piece  of  strangulated  gut.  She  was  again  operated 
upon,  and  was  getting  on  well,  when  a  gross  imprudence  in  diet  induced 
peritonitis,  of  which  she  died. 

The  Clitoris,  the  homologue  of  the  penis,  is  situated  at  the 
commencement  of  the  vestibule,  half  an  inch  behind  the  anterior 


DISEASES   OF    WOMEN. 


angle  formed  by  the  labia.  It  may  be  hypertrophied,  or  the  seat  of 
a  sarcomatous,  carcinomatous,  or  cystic  growth.  It  can  be  avoided 
in  digital  examinations  by  keeping  to  the  rectal  wall  of  the  vagina, 
and,  when  passing  the  catheter,  by  arriving  at  the  meatus  through 
the  guide  aiforded  in  the  cord-like  feel  of  the  urethra.  Masturbation 
leads  to  many  forms  of  nervous  mischief  in  women.  The  operation 
of  clitoridectomy  for  various  disorders  of  the  nervous  system,  more 
especially  epilepsy  and  hystero-epilepsy,  brought  on  by  masturbation, 
is  not  an  accepted  operation  in  this  country.  Rather  must  we 
combat  the  habit  by  judicious  moral  means,  with  healthier  mental 
and  physical  occupations  and  enjoyments.  Even  if  we  do  not  lead 
the  patient  to  believe  that  we  suspect  the  vice,  we  must  give  her  to 
understand  that  any  undue  excitement  of  the  external  organs  of 
generation  is  most  pernicious,  and  likely  to  be  followed  by  disastrous 
results.  Next  to  masturbation,  too  frequent  medical  examinations 
are  to  be  condemned,  especially  in  that  type  of  woman,  of  the 
neurotic  temperament,  who  can  ill  conceal  her  feelings. 

The  Uretlira. — The  shortness  of  the  female  urethra  saves  the 
woman  the  penalty  paid  for  every  additional  inch  in  length  of 
the  male  canal.  Its  dilatability  admits  of  digital  exploration  of 
the  bladder,  after  sufficient  dilatation  with  a  uterine  dilator.  In 
dilating  the  urethra,  as  pointed  out  by  8imon,  a  dilatation  of  2 
cm.  is  sufficient  to  enable  us  to  introduce  the  index-finger  into  the 
bladder.  I  always  prepare  the  way  for  the  finger  by  the  previous 
passage  of  my  graduated  dilators. 


Fig.  2. — Kelly's  Urethral  Calibrator. 
The  lines  indicate  tlie  diameter  in  millimetres. 

Howard  Kelly  uses  a  urethral  calibrator  for  exploring  the  bladder  in  his 
method  of  endoscopy  and  for  catheterization  of  the  ureters. 

'  The  calibrator  is  pushed  into  the  urethra  as  far  as  it  will  readily  go,  and 
the  marking  of  the  meatus  is  noted.'  This  indicates  the  calibre  of  the  dilator 
to  b.e  first  introduced.  '  The  average  female  urethra,'  he  says,  '  can  be  easily 
dilated  up  to  12  mm.  in  diameter,  with  only  a  slight  external  rupture.  I  have 
never  seen  a  tear  more  than  2  or  3  mm.  in  length,  and  from  1  to  IJ  mm.  in 
depth.' 

In  introducinsr  the  finger,  it  must  be  borne  in    mind  that  the 


ANATOMICAL    AM>    CLIMCAL. 


safety  with  which  it  is  done  depends  upon  the  size  of  the  digit  of 
the  operator,  and  also  on  the  care  and  gentleness  with  which  it  is 
inserted.  I  have  never  had  any  permanent  bad  results  from  such 
combined  instrumental  and  digital  exploration  of  the  bladder. 
Dilatation  renders  litholapaxy  (Bigelow's  operation),  or  lithotrity, 
comparatively  an  easy  operation  in  the  woman.  ^Ve  need  never 
experience  any  difificulty  in  relieving  the  female  bladder.  Any 
short  tube  over  3  inches  long,  which  has  been  disinfected,  will  suc- 
cessfully accomplish  the  necessary  operation,  if  we  happen  to  forget 
our  catheter. 

Any  little  warty  growth  above  the  nymphje  or  urethra  should 
demand  our  attention,  also  any  discharge  pouring  from  its  orifice. 
In  ordinary  vaginitis  the  orifice  of  the  urethra  has  not  generally  an 
inflamed,  pouting  appearance,  as  it  frequently  has  in  gonorrhceal 
inflammation.  Caruncle,  warts,  tumours,  and  hypertrophied  states 
of  the  nymphte  occasionally  occlude  the  orifice  of  the  urethra. 

Skene's  glands  are  two  mucous-lined  tubules,  branched  at  their 
distal  ends  on  the  free  surface  of  the  urethral  mucous  membrane 
inside  the  labia  of  the  meatus  urinarius.  Their  branched  upper 
ends  terminate  in  the  muscular  walls  of  the  urethra,  Howard 
Kelly  has  specially  studied  the  histology  and  function  of  these 
glands,  showing  that  they  furnish  a  lubricating  fluid  'for  protect- 
ing the  delicate  mucosa  from  harmful  attrition.'  These  tubules  are 
well  inside  the  small  protection  folds  of  the  labia  urethra;,  and 
can  be  felt  on  palpation  lying  parallel  to  the  urethra.  By  compres- 
sion their  secretion  can  be  expressed.  Their  minute  orifices  are 
visible,  and  can  be  explored  by  a  fiune  probe,  or  fluid  may  be  injected. 
The  glands  may  be  attacked  by  simple  catarrhal  or  suppurative  in- 
flammation. They  are  specially  liable  to  attack  from  gonorrhceal 
infection  and  any  purulent  discharge  in  cystitis."'  Howard  Kelly 
agrees  with  Max  Schiiller  in  regarding  the  tubules  as  true  glands. 
(See  also  chapter  on  '  AflTections  of  the  Urethra.') 

The  Vagina. — This  canal  measures  from  2^  to  3  inches  alopg 
its  anterior  wall,  and  3^  to  1  inches  posteriorly,  varying  in  length 
in  difierent  women,  and  in  the  virgin  and  multipara.  It  is  narrower 
below  and  above,  and  is  very  distensible  in  women  who  have  borne 
children,  widening  at  its  uterine  extremity.  It  is  enclosed  at  the 
sides  by  the  levatores  muscles.  Its  dilatability  in  atonic  states  of 
the   vagina  explains   the  large   acciunulation  of  gas  or  fluid  that 

♦  '  Labia  Urethrse  and  Skene's  Glan<ls,'  by  Howard  Kelly,  M.D.,  Amer.  Mtd., 
vol.  vi.,  Nos.  xi.  and  xii.,  September  12,  1903. 


DISEASES   OF   WOMEN. 


collects  in  the  canal.  The  lower  end  is  surrounded  by  the  striated 
muscular  fibres  known  as  the  sphincter  vaginae.  An  illustration  of 
these  facts  is  afforded  by  the  forcible  and  audible  expulsion  of  air 
which  occurs  occasionally  after  a  woman  has  been  in  the  genu-pectoral 
position.  The  muscularity  and  elasticity  of  its  walls  are  shown 
by  the  inherent  power  that  the  vagina   possesses  of  expelling  its 


Fig.  3. — Section  of  the  Body  of  a  Woman,  aged  Twenty-five,  .showing 
THE  Pelvic  Viscera  and  Perineum.  (Fkom  'Atlas  of  DEScrapxiVE 
Anatomy.'     After  Heitzman.)  * 

contents  ;  as,  for  example,  expulsion  of  the  after-birth,  the  speculum, 
or  physometrous  collections. 

The  columns  and  rugte  which  project  from  the  vaginal  walls  give 
cover  to  leucorrhceal  and  other  discharges.  We  speak  familiarly  of 
the  anterior  vaginal  and  posterior  vaginal  fornix — important  recesses, 

"*  The  uterus  here  is  in  a  displaced  position,  one  of  impending  retroversion 
(see  Fig.  13). 


ANATOMICAL   AND   CLINICAL. 


or  cul-de-sacs,  in  front  and  behind  the  uterine  neck,  needing  careful 
exploration  in  digital  examinations.  The  A^agina  is  materially 
influenced  by  the  acts  of  respiration,  being  depressed  during 
inspiration,  rising  again  during  expiration.  The  position  of  the 
bladder,  the  distension  of  the  rectum,  the  state  of  the  superin- 
cumbent viscera,  and  pressure  on  the  abdominal  wall,  all  affect  the 
vagina.  The  dense  bed  of  cellular  tissue  which  unites  it  to  the  base 
of  the  bladder,  and,  still  lower  down,  and  more  intimately,  to  the 
ui'ethra,  affords  a  clue  to  the  associated  movement  of  the  bladder, 
uterus,  and  vagina.  Its  connection  posteriorly  to  the  rectum, 
through  the  peritoneum  above  and  loose  cellular  tissue  inferiorly, 
explains  a  similar  association  of  the  moA^ement  with  this  viscus, 
though  in  a  less  degree.     We  have  thus  an  elastic  muscular  tube, 


Fig.  4. — Fkom  Bkaune,  shuwing 
Distended  Kectdm  and  Empty 
Bladder  (Pikagofe's  Section). 


Fig.  5. — Fkom  Bkaune,  showing 
Distended  Bladder(Piragoff's 
Section). 


iiitluenced  on  all  sides  by  the  surrounding  viscera.  It  has  connected 
with  it  an  organ  whose  weight  and  position  periodically  vary,  sub- 
lected  to  much  the  same  influences  from  its  surroundings  as  the 
vagina  itself,  and  by  which  it  is  in  great  measure  supported.  The 
only  sound  clinical  view  to  take  of  the  vagina  is  to  regard  it  as  the 
important  link  of  union  between  the  uterus,  rectum,  and  bladder, 
while  forming,  with  the  perineal  body,  a  support  for  the  uterus 
inferiorly.  Its  muscularity  further  endows  it  with  this  supporting 
power.  The  terms  '  canal '  and  '  tube '  are  apt  to  give  the  student 
an  erroneous  impression.  In  old  multipara,  in  cases  of  procidentia 
and  uterine  displacements,  or  when  there  are  abnormal  states  of 
the  bladder  or  rectum,  the  vaginal  walls  at  the  fundus  may  be 
separated.     We  have,  however,  only  to  watch  the  passage  closing 


DISEASES   OF   WOMEN. 


a'ter  an  ordinai-y  examination,  or  to  feel  for  ourselves — by  the 
introduction  of  the  finger — the  close  apposition  of  the  vaginal  walls, 
to  be  convinced  that  the  normal  condition  of  the  vagina  is  one  of 
complete  closure.  Two  most  important  pui'poses  are  thus  effected. 
Greater  support  is  obtained  for  the  uterus  above ;  the  entrance  of 
putrefactive  elements  is  prevented  from  below.  In  atonic  states, 
when  the  musculai'ity  of  the  vaginal  walls  is  lost,  we  lose  much  of 
this  advantage ;  the  uterus  sinks,  and  if,  as  unfortunately  is  often 
the  case,  the  perineal  body  also  suffers,  being  deficient  in  tone  and 
vitality,  or  injured  by  parturition,  the  uterus  becomes  still  more 
displaced,  dragging  with  it  the  anterior  vaginal  wall,  which  in  its 
turn  descends,  and  we  have  the  first  stage  of  the  subsequent  pro- 
cidentia or  prolapse.  These  clinical  results  are  all  intensified  by 
the  relaxation  of  the  utero-sacral  ligaments,  these  most  important 
supports  preventing  both  retroversion  and  prolapse.  Frequently, 
with  so  called  '  supports '  or  pessaries,  these  baneful  results  are  en- 
couraged, and  vaginal  uterine  support  is  weakened.  I  spealc  of  their 
misuse  and  inaccurate  application.  Perhaps  no  gynaecological  appliance 
is  still  more  commonly  abused  than  a  pessary.  To  fix  a  rigid  and 
immovahle  bar  or  ring  in  the  normal  vaginal  passage  is  essentially 
bai'barous  and  unscientific.  Yet  this  is  still  done  from  ignorance 
of  the  first  principle  of  a  uterine  support,  until  we  occasionally  have 
to  cut  it  out  of  the  vaginal  wall,  in  which  it  has  formed  for  itself  a 
bed. 

I  once  removed  with  much  difficulty  a  huge  vulcanite  ring  pessary  from 
the  vagina  of  a  patient  who  had  worn  it  without  removal  for  five  years,  and 
also  a  rubber  Hodge  which  had  remained  in  the  vagina  over  eight  years. 
The  latter  was  encrusted  with  hardened  mucus  and  calcareous  particles.  The 
entire  vaginal  cervix  was  deeply  eroded. 

The  vast  extent  of  the  mucous  membrane  of  the  vagina  explains 
the  difficulty  of  curing  vaginitis,  and  the  severity  of  gonorrhceal 
inflammation  in  the  female.  Its  folds  and  rugse  afford  hiding- 
places  for  secretion  and  impure  discharges.  Its  numerous  vascular 
papillae  (with  their  investing  epithelium  removed),  at  first  congested 
and  prominent,  finally  become  hypertrophied  and  granular. 

Influence  of  Posture  on  the  Vagina. 

The  influence  of  posture  on  the  vagina  is  of  importance.  In  the  dorsal 
position  the  vagina  remains  closed  ;  hence  after  many  operations  we  prefer  to 
keep  the  woman  in  this  position  for  a  certain  time.     I  am  still  of  opinion 


ANATOMICAL  AND   CLINICAL. 


tliat,  consistently  with  the  obvions  relief  that  occasionally  allowing,'  her  to 
turn  on  her  side  all'onls,  the  dorsal  decubitus  is  the  safest  post- operative 
position.  In  a  dorsal  examination  we  elevate  the  hips  while  the  patient  is  in 
this  position,  so  as  to  open  the  vagina  and  relieve  it  of  the  superincumbent 
weight  of  the  abdominal  viscera.  We  take  advantage  most  eflectively  of 
gravity  in  the  knee-elbow,  or  genu-pectoral,  position  :  the  woman  converts 
licr  elbows,  chest,  and  knees  into  a  form  of  tripod  (Fig.  6).  The  hips  and 
buttocks  are  thus  raised,  the  viscera  are  thrown  downwards  and  forwards 


Fig.    G. — PusiTii.ix   uf    thk   Body   ix    'jhe   CtExu-pectoeal   Position'. 
The  thighs  should  be  separated  more  than  is  shown  in  the  drawin"-. 

the  ovaries  (Goodell)  'are  put  to  bed.'  It  is  the  position  we  avail  ourselves 
of  in  some  vaginal  operations,  especially  for  vesical,  rectal,  and  uterine  fistulte. 
It  is  also  that  to  be  selected  in  certain  cases  of  retroversion  during  replace- 
ment of  the  organ,  and  should  be  adopted  periodically  by  the  patient  after 
this  has  been  effected.  In  it  the  vaginal  walls  separate,  and  most  readily 
open  when  the  examining  finger  is  inserted.  There  is  also  the  mechanical 
pressure  exercised  on  the  uterus  and  vaginal  walls  hy  the  imprisoned  air 
which  accumulates  in  the  vagina  during  manipulation  in  this  position. 

The  Hymen. — I  have  seen  one  case  where  the  hymen  was  rigid 
and  unruptured,  only  a  very  small  aperture  existing,  and  still  the 
patient  became  pregnant.  This  only  establishes  the  well-known 
fact  that  penetration  is  not  necessary  for  the  act  of  conception  to 
take  place.  Often  this  thickened  hymen  causes  trouble  after 
marriage  and  demands  interference.  In  most  cases  the  passage  of 
an  expanding  speculum  or  the  solid  glass  dilator,  the  patient  being 
under  an  anaesthetic,   will  quickly  rectify  this   defect.     In  others, 


10 


DISEASES   OF    WOMEN. 


resection  of  the  hymen  as  a  preliminary  step  is  required.  After 
such  forcible  rupture  and  dilatation  the  dilator  is  passed  daily,  or 
is  used  as  a  vaginal  rest  and  kept  with  a  T  bandage  in  the  vagina 
for  a  few  hours  at  a  time.     Fi'equently  in  such  cases  there  is  an 


:/ 


Td  li'g 


,j<^-^ 


Fig.  7. — View  op  the  Viscera  in  the  Inlet  or  Pelvis  from  above. 
(From  Howard  Kelly.) 

irritable  condition  of  the  vaginal  orifice,  and  some  slight  vaginitis 
present.  The  more  serious  condition,  '  imperforate  hymen,'  is  dealt 
with  in  the  chapter  on  '  Atresia  of  the  Vagina.' 

When  a  young  girl  at  the  age  of  puberty,  who  has  never  menstruated,  is 
brought  to  us  complaining  of  ill-defined  abdominal  pains,  and,  it  may  be,  some 
attendant  constitutional  symptoms,  we  should  always  satisfy  ourselves  that 
there  is  no  atresia  of  the  vaginal  passage  nor  any  occlusion  of  the  vulva.  Now 
and  then  we  meet  a  case  in  which  rigors  have  occurred,  and  there  is  high 
temperature,  with  rapid  pulse,  severe  abdQniinal  pain,  local  tenderness,  and 


ANATOMICAL   AND   CLINICAL.  11 


distension,  or  the  physical  signs  of  a  tumour  present.  Here,  with  ai 
imperforale  hymen,  we  may  suspect  peritonitis,  colpo-hajmatocele,  and  th 
greater  danger  of  septicajmia. 


Abnormalities  in  the  Hymen  :  Folding  Hymen. 

At  tlie  British  Gynecological  Society,  I  brought  forward  the  question  of 
the  condition  of  the  hymen  as  evidence  of  virginity  or  chastity.  The  follow- 
ing variations  in  the  nature  and  shape  of  the  hymen  have  been  described  by 
.\Iexander  Skene,  hymen  crihriformis,  hymen  with  a  number  of  small  openings  ; 
hymen  annularis,  hymen  with  one  small  central  opening;  hymen Jimbriatus, 
fringed  like  the  Fallopian  tube.  To  those  three  I  would  add  the  variety  I 
then  described  a?,  folding  hymen, 

Kinkead,*  of  Queen's  College,  Galway,  has  instanced  cases  in  which  frequent 
coition  had  taken  place,  and  others  in  which  labour  at  fidl  term  was  completed, 
without  injury  to  the  hymen.  Lombe  Atthill  has  alluded  to  this  yielding  of 
the  rubber-like  hymen  during  intercourse,  without  the  least  cracking.  In 
some  most  serious  cases  that  have  been  brought  to  me  for  an  opinion  as  to 
the  alleged  impotence  of  a  husband  or  the  chastity  of  a  woman,  and  in  which 
the  gravest  issues  were  involved,  I  found  this  'folding  '  form  of  hymen.  The 
hymen  was  quite  perfect  and  uninjured,  yet  a  fair-sized  speculum,  or  a  vaginal 
dilator,  could  be  passed  into  the  vagina.  The  membrane  simply  folded  back 
against  the  vaginal  wall,  retui'ning  again  to  its  normal  position  on  the  with- 
drawal of  the  instrument.  It  must  be  remembered  that  the  carunculse  are 
formed  by  child-bearing  only,  and  not  by  simple  laceration.  The  importance 
of  remembering  that  this  yielding  form  of  hjTnen  may  exist  is  obvious.  It 
may  have  a  critical  bearing  on  the  medical  evidence  in  a  case  of  supposed 
rape. 

Medico-legal  Bearings. 

The  following  examples  show  the  need  for  recognition  of  this  condition  of 
hymen  : — - 

I. — A  patient  was  brought  for  examination  who  had  been  recently  married. 
A  coolness  had  arisen  immediately  after  marriage,  o-wing  to  some  difficulty 
having  occurred  in  intercourse,  which  she  ascribed  to  ineffectual  efforts  on  the 
part  of  her  husband.  But,  contra,  he  alleged  that  she  had  resisted,  and  feigned 
such  great  pain  at  the  time  that  he  had  to  desist.  The  coolness  was  accen- 
tuated by  a  suspicion  of  previous  impmity  on  the  part  of  the  woman.  Upon 
examination,  the  hymen  was  found  complete,  but  of  the  folding  t}-pe.  An 
opinion  had  previously  been  given  that  the  woman  was  intact.  Subsequent 
disclosures  proved  that  she  had  lived  irregularly,  and  had  aborted  previous  to 
her  marriage. 

II. — A  patient  wished  to  establish  a  charge  of  impotence  against  her  husband. 

*  Paper  read  before  the  Eoyal  Academy  of  Medicine  in  Ireland  on  the  '  Proofs 
of  Virginity,'  by  E.  Kinkead,  December  29.  1887. 


12  DISEASES   OF    WOMEN. 

She  had  already  been  examined  with  this  object,  and  pronounced  intact.  It 
was  ascertained  that  there  had  been  only  a  few  occasions  on  which  sexual 
intercourse  could  have  occurred  within  a  given  number  of  months.  She 
strongly  resisted  internal  examination,  lest  the  hymeneal  proof  of  her  virginity 
should  be  destroyed.  Looking  at  the  hymen,  it  was  found  to  be  uninjured 
and  normal  in  appearance.  Casually,  during  examination,  a  slight  suprapubic 
enlargement  was  discovered.  This  aroused  suspicion,  which  the  appearance 
of  the  mammae  confirmed.  A  vaginal  examination  was  carefully  made,  and  a 
perfectly  yielding  hymen  was  found  of  the  nature  described.  Though  told 
that  she  was  pregnant,  the  patient  persisted  in  the  denial  of  cohabitation 
having  taken  place,  even  to  the  point  of  endeavouring  to  produce  medical 
evidence  of  her  chastity  in  a  case  for  nullity  of  marriage.  She  was,  however, 
confined  of  a  child  at  full  time  some  six  months  subsequently. 

III. — A  most  serious  charge  was  preferred  against  a  man,  which  he  in  part 
rebutted  by  exculpatory  evidence  on  oath  that  he  had  had  intercourse  with 
a  young  girl,  extending  over  a  considerable  period  of  time.  The  case  was 
one  in  which  the  gravest  issues  were  at  stake. 

The  girl's  cause  was  subsequently  taken  up  by  powerful  friends,  and  she 
was  submitted  to  medical  examination.  The  hymen  was  found  complete, 
and  upon  this  fact  medical  oiainions  were  elicited  that  it  would  have  been 
impossible,  or  at  least  improbable,  that  sexual  intercourse  could  have  been 
continued  over  such  a  length  of  time  as  that  stated.  She  was  brought  for  an 
expert  judgment  on  this  point. 

The  hj^men  was  found  as  already  described,  but  on  a  digital  examination 
being  made,  it  completely  yielded  and  folded  back. 

Ultimately,  without  any  force  or  difficulty,  a  fair-sized  conical  speculum  was 
passed,  and  also  a  comparatively  large  glass  vaginal  dilator,  without  the  least 
injury.  The  opinion  was  given  that  frequent  coition,  partial  or  complete,  was 
quite  feasible  under  the  conditions,  but  that  the  chastity  of  the  girl  was  not 
ivi'pugned. 

Nevertheless  legal  pressure,  only  stopping  at  the  point  of  dragging  an  un- 
willing and  hostile  medical  witness  into  court,  was  unsuccessfully  exercised  to 
force  an  opinion  that  it  was  not  possible  under  these  conditions  that  repeated 
copulation  could  have  happened. 

These  three  examples  are  sufficient  for  my  purpose.  In  them  we  have  the 
following  issues  involved  : — 

In  Case  1. — The  impotence  of  the  husband,  and  the  ante-marital  chastity 
of  the  wife,  as  bearing  on  the  question  of  nullity  of  marriage  or  separation. 

In  Case  2. — The  impotence  of  the  husband,  and  the  problematical  doubt 
raised  as  to  the  parentage  of  the  child. 

In  Case  3. — The  perjury  of  the  man  and  the  chastity  of  the  woman. 

A  case  came  under  my  notice  in  which  a  prolongation  of  the  perinoeum  in 
the  shape  of  a  fold  of  skin  covering  two-thirds  of  the  introitus  gave  rise 
to  a  plea  for  nullity  of  marriage.  Intercourse  had,  however,  frequently 
occurred. 

Perineum. — Sufficient  has  already  been  said  of  this  body  as  a 
support,  to  indicate  the  necessity  of  attending  to  any  old  lacerations 


ANATOMICAL   AND   CLINICAL. 


13 


or  rents.  Defect  of  the  perineal  body  is  one  of  the  most  frequent 
associated  causes  of  uterine  displacement.  We  also  learn  this 
important  lesson,  always  to  inspect  the  perineum  after  labour, 
especially  after  a  first  labour.  Many  a  small  rent,  the  soui-ce  of 
future  uterine  trouble,  escapes  notice  even  after  ordinary  labour. 
Let  us  always  regard  Goodell's  two  invaluable  hints — '  relaxation  of 
the  perineum  '  and  '  immediate  suture.'  To  *  relax  the  perineum  ' 
in  labour,  we  pass  the  fore  and  middle  fingers  of  the  left  hand  into 
the  rectum,  and  hook  forward  the  sphincter,  while  the  thumb  of  the 
same  hand  retards  and  modifies  the  pressure  of  the  advancing  head. 
The  harmful  old  practice  of  '  supporting  '  it  and  the  negligence  of 
postponing  the  closure  of  the  rent, 
have  cost  many  a  woman  an  infinity 
of  misery,  and,  through  a  septicaemia, 
induced  by  perineal  wounds  made  in 
operating  and  during  the  puerperal 
period,  have  occasionally  caused  peri- 
tonitis and  death. 

The  Pouch  of  Douglas, — This  im- 
portant space,  formed  by  the  utero- 
rectal  folds  of  peritoneum,  is  the 
receptacle  occasionally  of  an  intestinal 
loop,  a  prolapsed  ovary,  cystic  tumours, 
ovarian  tumours,  efiusions  of  lymph, 
pus,  and  blood.  Encroaching  on  it 
we  may  find  a  retroverted  uterus,  and 
pres.sing  upwards  into  it,  in  extreme 
cases  of  anteflexion,  the  cervix  uteri. 
Obstructing  it  posteriorly,  we  meet 
with  faecal  accumulation,  malignant 
growths  of  the  rectum,  and  sacral  tumours.  In  ordinary  conditions 
the  rectal  and  uterine  walls  of  Douglas'  space  are  in  apposition ; 
they  are  separated  by  tumours,  effusions,  and  anteverted  and 
anteflexed  states  of  the  uterus. 


Fig.  8. — Vkrtical  Section  of 
Uterus  (Kamsbotham). 


Examination  of  the  Pouch  of  Douglas. 

To  examine  this  space  properly,  an  enema  sliould  first  be  administered,  and 
the  rectum  gently  but  thoroughly  explored  with  the  finger.* 


•    Elsewhere  the  anatomical  peculiaiities  of  Ibe  rectum  hi  children  and  the 
clinical  bearing  of  these  are  discussed.     See  chapter  on  '  Steps  of  Examination.' 


14 


DISEASES   OF   WOMEN. 


It  is  better  tirst  to  partty  introduce  the  forefinger  of  the  left  hand,  well 
anointed  with  lard,  slowly  stretching  the  external  sphincter  to  either  side, 
and  then  gradually  insert  the  entire  finger  and  explore  the  rectum  ;  we  maj' 
detect  internal  hsemorrhoids,  polypus,  fissure,  nicer,  or  stricture  ;  a  collection 
of  fluid  in  Douglas'  pouch,  uterine  retroversion,  adhesions,  or  prolapse  of  an 
ovary.  In  retro-hsematocele,  and  pelvic  effusions,  such  an  exploration  is 
essential  to  define  their  nature — if  hard  and  resisting,  or  soft  and  yielding. 
Thus  we  niaj'  often  best  ascertain  the  sensitiveness,  or  degree  of  congestion, 
of  the  ovary. 

The  therapeutical  dilatation  of  the  rectum  under  an  ancesthetic  for  an  ex- 
cessive reflex  irritahility  of  the  sphincter,  with  dryness  of  the  mucous  mem- 
hrane,  hrought  on  occasionally  hy  erotic  practices,  is  dealt  vjith  in  the  rha/pter 
on  the  Rectum. 

The  Uterus. — It  is  right  that  we  should  always  have  before  our 
mind  what  are  the  dimensions,  size,  and  weight  of  the  healthy 
uterus  in  the  young  virgin,  and  in  the  adult  and  multiparous 
woman :  — 


Measurement  in  inches. 

From  Richet  and  Sappey. 

Virgin. 

Nulliparae. 

Multiparse. 

Entire  Uterus,  longitudinal 

2-20 

2-52 

2-72 

„               thickness 

!          0-85 

0-90 

1-00 

„              transverse     . 

1-22 

1-80 

1-90 

Cavity  of  Uterus,  transverse 

0-60 

1-08 

1-24 

length 

1-80 

2-20 

2-44 

Istbmus  uteri,  length 

.     0-20-0-25 

0.16 

„              width   . 

0-16 

„              antero-posterior 

012 

Grains. 

Grains. 

Weight       .... 

HOG  to  1000 

1200  to  1800 

Capacity     .          .          .          • 

2-2  c.  cm. 

o  5  c.  cm . 

The  uterus  in  the  perfectly  normal  condition  should  not  be  felt 
above  the  pubes.  It  is  felt  over  the  pubes  about  the  third  month 
of  pregnancy,  and  two  fingers'  breadth  above  it  at  the  fourth.  In 
the  natural  state  it  lies  ante  verted  in  the  pelvis.  It  is  included 
between  two  lines,  one  drawn  from  the  sacrovertebral  angle  to  the 
lower  border  of  the  pubic  bone,  and  the  other  carried  from  the 
inferior  margin  of  the  fourth  piece  of  the  sacrum  to  the  lower  border 
of  the  symphysis.  The  axis  of  the  uterus  obviously  varies  with  the 
condition  of  either  the  bladder  or  rectum.  This  is  well  seen  if  we 
note  the  position  of  the  uterus  as  represented  by  Kohlrausch,  and 


ANATOMICAL   AND    CLINICAL. 


15 


compare  it  with  the  diagrammatic  drawing  of  Schultze.  In  the 
former  the  bladder  is  distended,  while  the  latter  represents  the 
normal  position  of  the  virgin  uterus.     It  is  important  to  remember 


Fig.  9. — Lateral  Sectios  of 
Uterus.     (EAiisBOTHAjr.) 


Fig.  10. — From  Brauxe,  showing 
IJTEKrs  pressed  upox  by  Dis- 
ten-ded  Bladder  axd  Eectol 
(Legexdke.) 


how  freely  movable  the  healthy  uterus  is,  slung,  as  we  may  say,  in  the 
pelvis,  by  its  various  ligaments.     This  mobility  is  influenced  by  the 


Fig.  11.— Normal  Position  of  Yikgix  Uterus.     (Schultze.) 

size  of  the  uterus,  by  the  condition  of  the  surrounding  cellular 
tissue,  and  the  state  of  the  pelvic  ligaments— /a:a//on  of  the  uterus 
being  a  most  important  guide  in  the  diagnosis  and  prognosis  of 


16 


DISEASES   OF    WOMEN. 


various  uterine  affections.  It  is  frequently  fixed  in  fibroid  enlai'ge- 
ment,  in  malignant  disease,  by  pelvic  peritoneal  effusions,  and  in- 
cases of  retroversion  where  adhesions  exist.  We  are  enabled,  from 
its  normal  dimensions,  to  estimate  comparatively  its  increase  in  size 
in  morbid  states,  notably  in  fibroid  enlargement  and  subinvolution. 
The  dimensions  of  the  isthmus  explain  to  us  the  diflficulty  occa- 
sionally met  with  in  passing  the  uterine  sound,  and  how  essential 
free  dilatation  of  the  sphincter  uteri  is  in  any  form  of  intra-uterine 
medication.  They  also  explain  how  readily  the  narrow  canal  may 
be  closed  by  reflex  contraction,  by  irritation  or  inflammation,  and 
how  thus  secretions  or  medicated  solutions  are  imprisoned  in  the 
uterine  cavity.     Just  as  important  is  the  situation  of  the  isthmus 


Fig.  12. — Relative  Position  of  Pelvic  Viscera  when  the  Uteeus  is  pushed 
BACK  BY  A  Distended  Bladder.     (A.  Farre.) 

uteri  with  regard  to  the  reflected  utero-rectal  and  utero-vesical 
folds  of  the  peritoneum.  Above  and  below  the  isthmus  uteri  the 
organ  is  free,  being  supported  just  at  this  part  by  the  bed  of  cellular 
tissue  which  surrounds  it.  The  uterus  is  thus  balanced  in  the 
pelvis  by  the  reflections  of  peritoneum  and  encircling  cellular  tissue. 
The  uterus  has  the  tendency  to  bend  backwards  and  forwards  at 
this  situation — a  bending  still  further  increased  by  the  consequent 
constriction  of  the  bloodvessels,  at  the  junction  of  the  cervix  with 
the  body,  and  an  increase  of  weight,  posteriorly  or  anteriorly,  from 
congestion  of  the  tissues  or  small  myomata,  in  the  posterior  or  anterior 
wall  of  the  fundus  above  the   seat  of  constriction.      Constriction 


Fig.  13.* — Position  of  the  Pelvic  Okgans  in  the  Erect  Position 
(Hegar.) 


^f   .  30 


Fig.  13a. — Position  of  the  Pelvic  Organs  in  the  Dorsal  Position. 

(Hegar.) 

*  These  figures  are  from  Professor  Mangiagalli's   treatise  on  '  Diseases  uf 
Women,'  vol.  i.  [To  face 2^.  lU. 


N     20 


Fig.  13?>. — Position  of  the  Pelvic  Okgans  in  the  Dorso-saceal  Position. 

(Hegar.) 


M\60 


Fig.  13c. — Position  op  the  Pelvic  Oegans  in  the  Dokso-lumbau  Position. 

(Hegar.) 


ANATOMICAL   AND   CLINICAL.  17 

leads  to  congestion,  congestion  to  hyperplastic  effusion,  and  both  to 
tissue-formation,  tending  ultimately  to  contraction,  and  resulting 
flexion.  Flexion  produces  narrowing  or  twisting  of  the  uterine 
canal  at  this  spot,  and  stenosis,  with  all  its  consecutive  ills. 

Such  a  sequence  of  changes  produces  congestion  of  the  fundus 
uteri,  stenosis  of  the  cervix,  hyperplastic  effusion,  versions,  flexions, 
libroid  developments,  hardness  of  the  cervix,  amenorrhoea,  dysme- 
norrhoea,  and  sterility.  This  freedom  of  movement  teaches  us  also 
the  impoi-tance  of  not  overlooling  the  uterus  as  a  source  of  cesical 
irritation,  retention,  or  Ineontlnence  of  urine. 

Cure  of  Chronic  Incontinence  of  Urine  by  Rectification  of 
Displacement. 

A  patient  for  twelve  years  had  had  incontinence  of  urine,  until,  ultimately, 
she  was  shut  out  from  the  enjoyment  of  society,  and  had  always  to  wear  a 
diaper  or  urinal.  Her  life  was  miserable,  from  the  constant  passing  and 
dribbling  of  the  urine.  She  had  been  under  a  variety  of  ti'eatment.  The 
aiite-flexed  uterus  was  gradually  straightened  by  the  use  of  the  sound  and 
stem  pessaries.  The  bowel  Avas  carefully  attended  to,  and  the  general 
health  restored  by  suitable  tonics.  She  recovered  perfect  health  and  comfort, 
uor  was  there  at  any  time  the  least  tendency  to  unusual  irritation  of  the 
bladder.  Such  a  case  would  novj  he  one  foi'  treatment  hy  centro-siispension 
or  fixation. 

Cure  of  Incontinence  of  Urine  by  Ventro-fixation.* 

A  lad}',  aged  forty-eight,  suflered  from  incontinence  of  mine,  she  having 
for  some  time  been  obhged  to  wear  a  urinal.  During  my  examination  the 
mine  was  flowing  from  the  bladder.  There  was  a  large  ante-flexed  uterus, 
the  fimdus  of  which  lay  directly  forward  on  the  neck  of  the  bladder.  There 
was  also  anterior  vaginal  prolapse.  Three  days  after  the  operation  of 
ventro-fixation  was  performed  she  passed  her  urine  naturally,  and  there  was 
live  hours'  interval  between  the  emptying  of  the  bladder.  From  that  time 
to  the  present  she  has  passed  water  naturally,  and  can  retain  it  mthout  dis- 
tress for  seven  hom^.  [I  quote  this  case  as  it  was  the  first  I  treated  by 
this  operation.  Since  then  I  have  completely  relieved  several  equally 
obstinate  cases  of  incontinence  by  ventro-suspension.] 

Histological  Bearings  on  Clinical  Conditions. — In  studying 
interstitial  changes  in  the  uterine  wall,  and  the  invasion  of  the 
endometrium  and  submucosa  with  inflammatory  products,  as  well 
as  the  extension  of  inflammation  to  the  peritoneum,  it  is  important 
to  keep  in  mind — 

1.  The  thickness  of    the  muscular  coat  of  the   uterus.     This  is 

*  Transactions  Obstetrical  Society,  vol.  Ix.,  1899,  p.  tl2~. 

C 


18  PISJEASJUS  OF   WOMEN. 

hard  to  define,  in  consequence  of  the  intermixture  of  areolar  tissue 
between  it  and  the  mucous  lining  on  the  inside,  and  the  peritoneal 
tunic  externally.     It  probably  does  not  exceed  6  mm,* 

2.  The  thickness  of  the  mucous  membrane  and  the  large  inter- 
spersion  of  muscular  fibres  throughout  it. 

3.  The  concentric  arrangement  of  the  fibres  at  the  orifices  of  the 
Fallopian  tubes,  and  the  transverse  sphincter  fibres  at  the  external 
and  internal  os. 

4.  The  greater  firmness  of  the  cervical  mucous  membrane  as 
well  as  its  hardness,  as  compared  with  that  of  the  body,  and  the 
stratified  character  of  the  epithelium  of  the  lower  portion  of  the 
cervical  canal,  and  the  presence  of  numerous  vascular  papillee. 

Uterine  fibroids,  collections  of  fluid  or  old  efi'usions  in  Douglas' 
space,  relaxation  of  the  utero-sacral  supports,  will  also  throw 
the  uterus  forwards,  and  press  it  against  the  bladder.  How 
obviously  prudent,  then,  is  the  general  rule  in  all  cases  of  vesical 
trouble  in  women,  loliere  no  other  explanation  is  otherwise  afforded, 
to  malce  a  vacjinal  examination  and  ascertain  the.  condition  of  the 
uterus  ! 

The  ready  manner  in  which  slight  swelling  of  the  mucous  lining 
of  the  narrow  canal  of  the  isthmus  uteri  may  cause  its  closure  and 
imprison  secretions,  forces  on  us  the  importance  of  the  safe  rule, 
alwaijs  to  dilate  the  canal  of  the  cervix  before  internal  medication  of 
the  cavity  of  the  fundus,  and  to  maintain  that  dilatation  when  there 
is  any  suspicious  flow,  especially  of  a  htemorrhagic  character,  from 
the  interior  of  the  uterine  cavity. 

This  same  fact  shows  how  futile  are  those  abortive  attempts  to 
treat  mechanical  dysmenorrhcea  associated  with  sterility,  or  ordinary 
congestive  dysmenorrhcea  consequent  upon  stenosis  of  the  os  uteri, 
by  any  of  those  playful  slitting  operations  of  the  cervix  that  do 
not  reach  the  real  cause  of  the  obstruction,  disappointing  alike  the 
patient  and  practitioner.  The  stress  laid  on  the  essential  axiom, 
thoroughly  to  divide  the  canal  of  the  cervix  uteri  and  to  maintain 
its  dilatation,  in  cases  of  stenosis,  was  one  of  the  features  in  the 
impressive  teaching  of  the  late  Marion  Sims. 

The  Uterine  Lig-aments  and  the  Pelvic  Fascia. — While  the 
mechanical  purposes  secured  by  these  ligaments — more  especially 
the  utero-sacral,  broad,  and  round  ligaments — in  supporting  the 
uterus  and  maintaining  it  in  position  are  not  forgotten,  there  are 
some  other  matters  connected  with  their  attachments  and  relations 
*  Quain's  '  Anat.,'  10th  ed..  vol.  iii.  part  iv. 


ANATOMICAL   AXD    CLIXICAL. 


19 


that  must  not  be  overlooked.     The   uterus  is  mainly   retained  in 
position  by  the  recto-uterine  aud  utero-sacral  folds  of  peritoneum. 


Fig.  14. — UrEUUfi  and  Appexdages.     Diagrammatic  View  (•  Ql'Ain's 
Anatomy  '). 

In  the  dragging  on  and  stretching  of  these  we  have  doubtless  a 
ready  explanation   of  the  characteristic  sacral  pain  so  frequently 


Fig.  li>. — Vascular  Eelatioxs  of  Uterus?,  Ovary,  and  Fallopian  Tube,  seen 
FROM  THE  Front.    (From  Howard  Kelly.) 

Ur.,  ureter ;  U. A.,  uterine  artery;  U.V.,  uterine  vein ;  O. A.,  ovarian  artery ; 
O.V.,  ovarian  vein. 

complained  of.  As  we  shall  see  in  treating  of  backward  displace- 
ments, they  are  the  most  important  of  all  the  pelvic  ligaments  in 
the    8eti(jlogy    of    retroflexion.       These    recto-uterine    folds    contain 


20  DISEASES  OF   WOMEN. 


betwieen  their  layers  both  fibrous  and  smooth  muscular  tissue,  and 
it  is  of  importance  to  remember  that  some  of  these  muscular  fibres 
reaching  backwards  to  the  rectum  constitute  the  recto-uterine 
muscle,  while  others,  attached  to  the  front  of  the  septum,  form  the 
utero-sacral  ligament.  In  some  cases  '  the  recto-uterine  folds  are 
continuous  with  one  another  across  the  middle  line  behind  the 
cervix  uteri.'  *  The  vascular  and  sensitive  round  ligaments  con- 
tribute their  share  to  the  support  of  the  uterus,  and  may  serve  to 
favour  conception  (Rainey),  through  the  muscular  power  with 
which  they  are  endowed,  in  altering  the  direction  of  the  uterus. 
When  they  are  put  on  the  stretch  and  dragged  ori,"  as  in  displace- 
ments and  in  procidentia,  we  have  a  satisfactory  clue  to  the  pain 
complained  of  as  running  in  the  course  of  these  ligaments,  so  fre- 
quently accompanying  congested  states  both  of  the  uterus  and 
ovaries.  (The  reader  will  find  these  points  more  fully  referred  to 
in  the  chapter  on  '  Retroversion  of  the  Uterus.'^ 

Cunningham,  in  describing  the  recto-uterine  folds,  says :  '  Each 
contains  between  its  layers  a  considerable  amount  of  smooth 
muscular  tissue.  Some  of  these  fibres,  which  are  continuous  with 
the  uterine  wall,  pass  backwards  to  reach  the  rectum,  and  con- 
stitixte  the  recto-uterine  muscle ;  others,  gaining  an  attachment  to 
the  front  of  the  sacrum,  form  the  utero-sacral  ligament.' 

Structure  of  the  Round  Ligaments — Bearing  on  Hernia  and 

Growths. 

The  anatomical  points  of  gyneecological  interest  in  connection  widi  the 
round  ligaments  are  the  permanency  of  the  plica  gubernatrix  from  the 
Wolffian  bodj'  (the  analogue  of  the  gubernaculum  in  the  male),  constituting 
the  round  ligament  of  the  ovary  in  the  female,  its  attachment  to  the  uterus 
arresting  the  descent  of  the  ovary,  except  in  rare  cases  when,  passing  by  the 
canal  of  Nuck,  the  ovary  may  reach  the  labium  ;  the  peritoneal  accompani- 
ment of  the  round  ligament,  which  corresponds  to  the  processus  vaginalis  in 
the  male,  and  which,  when  not  obstructed,  forms  in  its  prolongation  the 
patent  canal  of  Nuck ;  thirdly,  the  presence  of  areolar  tissue  and  vessels  in 
and  around  the  round  ligament,  and  the  prolongation  of  the  transversalis 
fascia  from  the  internal  abdominal  ring.  Now,  by  these  anatomical  data  wc 
can  explain  the  presence  of  intestinal  hernia,  epiplocele,  hydrocele,  incarce- 
rated ovarj',  and  a  cyst  or  fibroma  in  the  canal  and  labium.  The  diagnosis  is 
not  always  easy.  Pozzi,  in  speaking  of  the  fluid  contained  in  cysts  in  the 
canal,  says  that  the  persistence  of  the  canal  of  Nuck  is  looked  upon  by  most 
authorities  as  explaining  the  presence  of  such  cysts,  though  this  is  denied  by 
Duplay ;  and  Schroeder  has  reported  a  case  in  which  he  was  able  to  return 
the  fluid  into  the  abdomen,  thus  demonstrating  a  communication  of  the  cyst 

*  D.  J.  Cunningham,  F.R.S.,  'Text-book  of  Auatomv,'  1902. 


I 


ANATOMICAf.    .WD    ('LIXfCAL.  21 

with  the  peritoneal  cavity,  and  establisiiing  a  resemblance  to  congenital 
hernia  in  the  male.  This  exactly  occnrred  in  one  of  my  own  cases.  Some- 
times the  cyst  may  be  seated  in  the  interior  of  the  round  ligament.  This  may 
be  due  to  a  persistence  of  the  female  gubernaculum  in  its  foetal  form  (Weber). 

Pelvic  Fascia. — Remembering  the  disposition  of  the  pelvic  fascia, 
we  can  understand,  the  association  between  over-distended  con- 
ditions of  the  bladder  and  uterine  discomfort,  from  the  connection 
of  the  bladder  and  uterus  through  the  utero-vesical  ligaments, 
while  the  general  distribution  of  the  uterine  and  pelvic  peritoneum, 
and  the  intimate  association  between  it  and  the  extensive  fascia  of 
the  pelvis,  oifer  a  ready  explanation  of  the  i-apid  transitional  phases 
of  uteiine  and  pelvic  inflammation — metritis  passing  into  peri- 
metritis, and  general  peritonitis  as  a  sequence  to  both.  From  the 
broad  ligaments  above  to  the  sciatic  notches  below,  we  have  the 
complete  continuity  of  the  cellular  tissue  maintained.  A  match 
struck  at  one  end  of  the  train  quickly  lights  the  mischief  that  with 
lightning  rapidity  often  spreads  until  the  entire  pelvic  viscera  are 
involved,  the  force  of  the  conflagration  being  still  further  heightened 
by  the  adjacent  peritoneum  taking  on  inflammation,  and  a  localized 
or  general  peritonitis  ensuing. 

Infra- Vaginal  Portion  of  Uterus  and  Os  Uteri. — The  infra- 
vaginal  portion  of  the  uterus,  or  that  projecting  into  the  vaginal 
passage,  has,  at  the  apex  of  the  rounded  cone,  the  opening  leading 
to  the  canal  of  the  uterus.  The  importance  of  the  division  of  the 
cervix  uteri  into  a  supra-vaginal,  infra-vaginal,  and  intermediate 
portion,  is  obvious  when  we  consider  the  pathology  of  prolapse  or 
hypertrophic  elongation.  The  infra- vaginal  portion  varies  in  length, 
but  it  may  be  taken  at  from  half  to  three-quarters  of  an  inch.  By 
the  length  and  shape  of  this  vaginal  portion,  and  the  character  of 
the  OS  uteri,  we  can  form  a  fair  opinion  of  the  condition  of  the 
uterus.  Its  shape  and  size  may  be  altered  ;  either  it  is  shortened, 
or,  on  the  other  hand,  hypertrophied  and  elongated.  Instead  of 
the  characteristic  sensation  of  yielding  a  little  to  the  flnger,  it  may 
be  either  very  soft,  or,  on  the  contrary,  hard  and  resisting.  Take 
as  an  example  of  the  former  condition  the  uterus  of  pregnancy,  and 
of  the  latter  the  hardened  cervix  in  fibroma,  or  the  characteristic- 
hardness  of  schirrus.  It  may  be  nipple-shaped,  as  in  many  cases 
t>f  fibroid,  and  the  infra-vaginal  portion  appear  to  the  examining 
finger  to  move  over  the  body  of  the  uterus,  like  the  nipple  of  the 
breast  over  a  hard  mammary  tumour.  The  conical  form  may  be 
lost,  and  we  search  for  the  small  '  pinhole '  orifice  of  the  os  uteri, 
and  detect  it  at  times  with  difScultv.     Or  the  short  cervix  runs 


22 


DISEASES   OF   WOMEN. 


sharply  to  a  pointed  cone,  in  the  very  apex  of  which  is  the  orifice  of 
the  OS  externum. 


The  Os  and  Cervix  Uteri. 

To  digital  touch  the  os  uteri  varies  in  shape,  size,  and  character, 
from  the  typical  os  uteri  with  its  anterior  and  posterior  lips 
running  transversely — giving  to  the  finger 
(Cruveilhier)  a  sensation  like  the  feeling 
of  the  cartilage  at  the  end  of  the  nose — ■ 
to  the  mere  slit,  slight  fissure,  or  small 
circular  aperture,  and  occasional  absence 
of  the  orifice  with  atresia  of  the  uterine 
canal.  With  this  congenitally  small  open- 
ing and  cervix  we  often  find  associated 
dysmenorrhcea,  ovarian  pain,  and  sterility. 
In  multipara  the  os  may  be  large  and 
dilatable,  admitting  the  point  of  the  finger ; 
or  fissured  and  lacerated  as  a  consequence 
of  labour  or  instrumental  delivery.  In 
pregnancy  it  partakes  of  the  characteristic 
general  softening  of  the  cervix,  and  hence 
it  has  more  of  a  velvet-like  feeling,  and 
is  soft  and  patulous.  It  is  frequently 
filled  with  tenacious  mucus,  which  is  so 
difficult  to  remove,  and  in  varying  degrees 
of  ropiness,  hangs  from  it,  a  frequent  cause  of  sterility. 


Fig.  16.  —  Diagram  of 
Uterus  to  show  Division 
OF  Cervix.   (Schroeder.) 

a,  iufra-vfiginal ;  h,  inter- 
mediate ;  c,  supra-vaginal ; 
dotted  line  shows  perito- 
neum. 


Fig.  17. — Coxge>-ital  Stenosis. 
rin-liolc,  OS  uteri  («)  ;  common  form  of  conical  cervix  Qi). 


ANATOMICAL    AXl>    CLINICAL. 


23 


Uterine  and  Vaginal  Secretions.  —  There  are  some  general 
considei-iitions  that  Ijear  on  our  knowledge  of  normal  uterine  and 
vaginal  secretions  and  discharges.  It  is  well  to  remember  the  close 
and  intimate  connection,  permeability,  and  porous  nature  of  the 
uterine  tissues.  This  is  of  importance,  and  explains  those  metritic 
troubles  which  have  arisen  after  intra-uterine  medication,  inde- 
pendently of  the  passage  of  any  fluid  into  the  Fallopian  tube.     The 


Fig.  18.— Lymphatics  of  thk  Pelvic  Okg.\n.-^.     (Huw.\kd  Kelly.) 

Sliowing  the  h-mphatics  accompanying  tlie  arteries  and  the  anastomoses  with 
tlie  lumbar  glands ;  the  dense  ramifications  on  the  uterine  wail  and  their 
anastomoses  with  the  above  or  traced  downwards  to  the  inguinal  glands. 
The  tributaries  of  communication  of  the  lymphatics  of  the  external  genitals 
and  lower  part  of  the  vagina  likewise  reach  the  inguinal  glands. 

.size  of  the  uterine  veins  throws  light  on  the   frequent  occurrence 
of  thrombosis  and  septicfemia. 

The  large  number  of  lymphatics  distributed  throughout  it.s 
tissue.';,  and  their  free  communication  with  the  lumbar  and  pelvic 
ganglia,    render    this   organ  peculiarly  prone   to  septic   absorption. 


24 


DISEASES    OF    WOMEN. 


Now  that  the  operation  of  curettage  is  so  frequently  performed, 
this  anatomical  fact  should  be  kept  in  mind,  '  Scraping '  of 
the  womb,  an  unfortunate  term  that  has  now  passed  into  popular 
use,  is  so  commonly  resorted  to  that  the  need  for  special  care 
in  previous  dilatation  and  strict  antiseptic  precautions  is  apt 
to  be  overlooked.  Elsewhere  in  dealing  with  the  operation  of 
curettage  this  caution  is  emphasized.  The  normal  mucous  plug 
that  fills  the  cervix  uteri  helps  to  ward  off  sej)tic  change  by  pre- 
venting the  admission  of  air  into  the  uterine  cavity.  It  comes  from 
the  cervical  glands,  is  alkaline,  is  washed  away  by  the  menstrual 
flow,  and  does  not  interfere  with  the  passage  of  the  spermatozoa. 
Elsewhere  (see  chapter  on  '  Stei'ility ')  the  eifect  of  the  vaginal  and 


Fifi.  10. — Diagram  of  the  Vascular  Supply  of  the  Vagixa,  Uterus  anh 
Ovary.    (Modified  prom  Hyrtl.) 

cervical  secretions  on  the  spermatozoa  in  causing  sterility  is  referred 
to.     The  epithelium  found  in  the  discharge  is  dentated. 

The  mucous  membrane  of  the  cavity  of  the  uterus  and  of  the 
Eallopian  tubes  secretes,  on  the  contrary,  a  whitish  alkaline  mucus, 
not  so  tenacious,  with  columnar  ciliated  epithelium  contained  in  it. 
This  secretion  is  often  profuse,  and,  on  examination  with  the  speculum, 
we  see  it  poured  out  in  quantity  from  the  uterus. 

Very  different  is  the  secretion  commonly  found  at  the  fundus  of 
the  vagina,  and  the  neighbouring  cervix  uteri.  It  comes  from  the 
outer  surface  of  the  cervix  and  adjoining  vaginal  wall.  The  epithe- 
lium is  squamous,  the  reaction  is  acid.  The  remainder  of  the  vaginal 
mucous   membrane    secretes   an  acid   (squamous)    mucus    and    the 


AXATO.VWAf.    AND    CLINICAL. 


25 


sebaceous  glands  of  the  vulva  pour  out  an  oily  secretion.  The 
Fallopian  tube  or  oviduct  is  contained  in  the  free  edge  of  the  broad 
ligament,  which  '  forms  a  kind  of  curtain  over  the  gland,  while  the 
latter  comes  to  lie  in  the  "bursa  ovaria,"  or  pocket,  formed  by  the 
ligament '  (Cunningham) ;  thus  floating  free  in  the  pelvis,  they  enter 
the  uterine  wall  at  their  inner  ends.  Traced  from  the  uterus,  they 
pass  almost  horizontally  onwards  for  a  distance  of  from  half  an  inch 
to  an  inch,  until  they  reach  the  side  wall  of  the  pelvis,  after  which 
they  ascend,  frequently  in  a  tortuous  manner,  in  front  of  their  corre- 
sponding ovaries,  and  then  arch  backwards  from  these  glands,  and, 
internally,  to  their  suspensory  ligaments.  Turning  downwards,  the 
fimbrije  are  opposite  the  inner  surfaces  and  posterior  iDordei-s  of  the 
ovaries'  (Quain). 


Submucous  layer. 


"  I 'iliatcJ  epithelium. 


Circular  muscular  fibres. 


LoQsitudinal  fibres. 


FrG.  20. — Normal  Fallopian  Tube  ix  Section.  (  x  10  diameters.)  (Macalisteh.)* 

The  Fallopian  tubes  are  liable  to  twists  and  bend.s,  and  to  con- 
tract adhesions  to  adjacent  parts,  while  their  connection  with  the 
ovaries  and  uterus  render  them  liable  to  every  influence  which  any 
change  in  the  position  of  these  latter  organs  exerts. 

The  dift'erent  portions  of  the  Fallopiaa  tube,  the  isthmus,  ampulla,  neck, 
and  fimbriated  end.  all  have  their  clinical  and  pathological  interest  for  tlie 
surgeon.  These  various  points  will  come  into  prominence  in  the  discussion 
of  morbid  states  of  the  tube  and  the  arrest  of  the  o'siim  in  any  part  of  it  in 
ectopic  gestation. 

Owing  to  the  small  calibre  of  the  uterine  portion  of  the  tube 

(0-12  of  an  inch  in  diameter),  and  the  fact  that  its  orifice  is  filled 

*  See  chapters  on  diseases  of  the  Fallopian  tubes  for  seotiona  of  diseased 
tubes ;  also  chapters  on  Tuberculosis  of  the  Genitalia  and  Ectopic  Gestation. 


26 


DISEASES   OE    WOMEN. 


with  mucus,  it  follows  that  fluid  is,  as  a  rule,  prevented  from  passing 
from  the  uterine  cavity  into  the  Fallopian  tube.  If  this  plug  be 
disturbed,  or  the  tube  be  more  patent  than  usual,  fluid  may  then 
readily  find  its  way  into  the  peritoneal  cavity. 

Tyler  Smith,  recognizing  the  patent  condition  of  the  uterine  orifice,  sug- 
gested catheterization  of  the  tubes  in  cases  of  obstruction,  tubal  gestation, 
etc.  Matthews  Duncan  drew  attention  to  this  abnormal  patency,  and  pointed 
out  that  it  afforded  an  explanation  of  the  passage  of  the  sound  out  of  the  uterus 
in  certain  cases.  This  I  satisfied  myself  of  in  a  woman  sent  for  operation  for 
ovarian  tumour.  On  several  occasions  the  sound  passed  readily  its  entire 
length,  though  the  uterus  was  not  enlarged,  as  was  proved  on  operation.  The 
explanation  lay  in  the  passage  of  the  instrument  into  the  peritoneal  cavity 
through  the  patent  tubal  orifice. 

Repeated  attacks  of  salpingitis  or  recurrent  pelvic  peritonitis  with 
consequent  adhesions,  influence  the  size,  position,   and  patency   of 
J  I 


Fig.  21. — Vertical  Sectiox  through  the  Broad  Ligament.     (Anderson.) 

A,  Fallopian  tube :  B,  tubal  branch  of  ovarian  vessels ;  C,  parovarium  ;  D,  ovarian  artery  ; 
E,  round  ligament  and  funicular  vessels ;  F,  connective  tissue  and  unstriped  muscle  (ntero- 
pelvic  band) ;  G,  uterine  veins ;  H,  uterine  artery ;  I,  ovary  ;  J,  ureter  ;  K,  reflected  peri- 
toneum. 

the  tubes  and  their  power  of  grasping  the  ovary.  We  frequently 
find,  in  cases  of  sterility,  thickened  states  of  the  broad  ligaments, 
adherent  ovaries,  contractions  and  adhesions  in  the  vaginal  roof. 
The  menstrual  secretion  may  thus  be  retained  in  the  Fallopian 
tube.  This  retention  and  various  other  causes  lead  to  its  dilatation, 
while  fluid  accumulation  and  cysts  are  occasionally  the  cause 
of  its  distension,  as  occurs  in  hydro-salpinx,  haemato-salpinx,  and 
pyo-salpinx.  The  causes  and  consequences  of  tubal  pregnancy  are 
discussed  in  the  chapter  dealing  with  this  complication.  The 
occurrence  of  salpingitis,  as  a  consequence  of  inflammation  of  the 
cavity  of  the  uterus,  and  especially  as  a  sequence  of  gonorrhceal 
infection,  is  also  readily  understood. 


A\A:rOM/CAL   AND   CLiyiCAL 


27 


The  Ovary.*-  The  ovary  at  either  side  of  the  pelvis  is  in  its 
normal  state  about  the  size  of  a  large  almond,  weighing  from  80  to 
100  grains.  The  position  of  this  gland,  whether  its  long  axis  be 
vertical  or  situated  obliquely  and  parallel  with  the  iliac  vessels,  is 
differently  described  by  His  and  Kolliker.  Cunningham  gives  the 
vertical  as  most  usual  position  {loc.  cit.).  In  old  age  the  gland 
atrophies  and  becomes  fibi'ous.  Its  exact  position  is  determined  by 
the  surrounding  viscera  and  the  position  of  the  uterus,  though  the 


Fig.  22. — Section  op  the  Pelvis  showing  the  Ligaments  op  the  TjTEKrs. 

(Anderson.) 
1,  Os  pubis;  2,  obturator  iuternus;  3,  obturator  fascia  ;  4,  sub-peritoneal  tissue;  5,  utero-pelvic 
ligament ;  6,  peritoneum  ;  7,  sacro-sciatic  ligament  ;  S,  rectum  ;  9,  utero-sacral  ligament, 
running  forward  into  recto-uterine  ligament;  10,  symphysis;  11,  prevesical  fat;  12,  bladder 
wall;  13,  vesical  cavity;  14,  peritoneum  of  utero-vesical  pouch;  15,  utero-vesical  ligament 
and  broad  ligament;  IB,  uterus  ;  11,  Douglas'  pouch  ;  18,  vessels;  19,  ureter  ;  20,  sacrum. 

gland,  as  a  rule,  lies  posteriorly  and  laterally  in  the  pelvis,  the  left 
being  in  close  proximity  to  the  rectum,  and  about  1  inch  from  the 
uterus. 

Ciinningliam  gives  the  position  of  the  ovary  in  the  fossa  ovarica  as  follows  : — 
Its  upper  pole  lies  below  the  level  of  the  external  iliac  vessels,  and  its  lower 
end  is  placed  just  above  the  level  of  the  peritoneum  covering  the  pelvic  floor. 
In  front  of  the  fossa  ovarica  is  the  obliterated  hypogastric  artery,  and  behind 
it  the  ureter  and  uterine  vessels.  Its  inner  surface  is  almost  completely 
covered  by  the  Fallopian  tube,  which  arches  over  its  upper  pole,  then,  turaing 
down,  to  the  posterior  part  of  its  inner  circle. 
I*  See  alsolchapter  on  the  diseases  of  the^ovaries  for  the  histology  of  the  ovary. 


28 


DISEASES   OF    WOMEN. 


According  to  Henle,  there  are  some  72,000  Graafian  follicles  in  the  two 
ovaries.  The  escape  of  the  ovules  and  the  ovum  gives  us  the  false  and  the 
true  corpora  lutea.  The  process  of  ovulation  is  accompanied  by  the  rupture 
of  one  of  these  follicles.  These  pei'iodical  ovarian  enlargements  are  attended 
by  increased  flow  of  blood  to  the  ovary,  temporary  congestion,  and  an  increase 
in  its  weight.  Should  the  Fallopian  tube  not  grasp  the  ovary  when  this 
follicle  has  ripened  and  burst,  the  ovule  may  fall  into  the  peritoneal  cavity, 
or  blood  may  escape  into  it.  The  ovary  and  the  uterus  have  such  intimate 
connections,  both  in  their  peritoneal  coverings  and  in  the  arterial  and  venous 
supplies  (the  utero-ovarian  arteries  and  veins),  that  any  congested  condition 
of  the  one  must  react  on  the  other.  This  is  seen  in  the  contemporaneous 
and  relative  increase  in  size  of  the  ovarian  arteries  and  veins  during  gestation. 


OvJTt. 


Fig.  23, — From  Howard  Kelly,  showing  Ovarian  Artei;ial  Sum-ly  and 
Distribution  or  the  Ovarian  Artery. 


Taking  this  vascular  association  of  the  ovary  and  uterus  into  consideration, 
with  the  equally  close  lymphatic  distribution  of  both  ovarian  and  uterine 
lymphatics  through  the  lumbar  glands,  we  have  no  difficulty  in  understanding 
how  purulent  and  septicsemic  processes  commencing  in  the  uterus  influence 
the  ovaries,  or  the  manner  in  which  such  a  condition  as  gonorrhceal  inflam- 
mation, if  unchecked,  is  generally  attended  by  a  greater  or  less  degree  of 
salpingitis  and  ovaritis.  In  the  large  vascular  supply  of  the  ovaries,  and  tlie 
periodical  alteration  in  the  quantity  of  blood  circulating  through  the  ovarian 
stroma — a  blood-supply  which  is  frequently  depraved — we  see  a  reason  for 
the  many  morbid  changes  occurring  in  the  ovarian  tissues,  and  which  are 
associated  constantly  with  vicious  menstruation.  On  the  one  hand,  w^e  find 
congestion  leading  to  hypertrophy,  hyperplasia,  and  sclerosis ;  ovarian 
apoplexy,  rupture  of  vessels,  the  formation  of  cysts  or  fibromata ;  on  the 


PLATE   A. 


Skctiox  of  the  INIatcke  Ovaky,  illustrating  the  Various  Stages  ix  the 
Development  and  Kegression  of  the  Graafian  Follicles. 

Within  some  of  the  follicles  the  discus  proligerus  is  clearly  visible.  Some  ha^vc 
undergone  cystic  degeneration,  while  others  are  represented  by  corpora 
lutea  in  various  stages  of  cicatrization,     (x  30  times.) 

[To  face  p.  28. 


PLATE   B. 


Human  Ovum. 

Shows  under  a  high  magnification  (upwards  of  400  diameters),  a  partially 
matured  Graafian  follicle  lying  in  the  ovary.  In  the  centre  is  seen  the 
nucleus  of  the  ovum,  containing  a  nucleolus,  and  surrounded  by  the 
granular  protoplasm  of  the  ovum.  The  zona  pellucida — the  hyaline  limit- 
ing membrane  of  the  ovum — is  visible,  though  not  yet  fully  formed.  Out- 
side it  is  the  membrana  granulosa,  consisting,  at  this  stage,  of  a  double 
layer  of  cubical  cells,  with  radially  arranged  nuclei.  Most  externally  the 
ovarian  stroma  in  the  neighbourhood  is  becoming  condensed  to  form  the 
tunica  fibrosa.  The  cells  of  the  tunica  granulosa  have  not  yet  commenced 
to  form  the  liquor  folliculi. 

lTofucep.2d. 


ANATOMICAL    ANT)   CLINICAL.  29 


other,    antemic    conditions   tending   to  irregular,    arrested,   or    suppressed 
menstruation. 

Our  knowledge  of  the  physiological  function  discharged  by  the 
ovaries,  and  the  intimate  dependence  of  the  woman's  physical  and 
mental  health  on  the  nature  of  the  menstrual  act,  forces  us  to 
regard,  as  of  primary  importance  to  her  physical  well-being,  the 
health  of  her  ovaries,  and  the  correct  discharge  of  the  function  of 
ovulation.  One  of  the  greatest  advances  in  gynaecological  science 
was  the  operation  of  removal  of  the  ovaries,  first  proposed  by 
Battey,  of  Georgia,  for  inducing  the  premature  change  of  life  in 
woman,  in  various  morbid  states  of  both  uterus  and  ovaries.  With 
this  step  the  name  of  Lawson  Tait  is  inseparably  connected,  as  he 
first  insisted  on  the  part  played  by  the  Fallopian  tube  in  the  act  of 
menstruation,  and  the  need  for  its  complete  removal  together  with 
the  ovary,  in  the  operation  for  removal  of  the  uterine  appendages. 

Of  late  years  the  conservative  operations  on  the  ovaries  and  Fallopian 
tubes  (to  be  fully  descrihed  further  on)  have  revolutionized  the  surgery  of 
the  adnexa.  To  remove  only  such  adnexa  as  are  diseased  and  dangerous, 
and  to  conserve,  as  far  as  possible,  healthy  organs,  by  resection  both  of  the 
tube  and  ovary,  are  the  principles  which  guide  the  surgeon. 

It  should  be  remembered  that  in  rare  instances  the  ovary  descends  to  the 
labium  following  the  course  of  the  gubernaculum.  or  is  an-ested  in  the 
inguinal  canal  (^vidc  Round  Ligaments). 

Ovulation  and  Menstruation. 

Process  of  Ovulation — General  Observations. — To  comprehend  any 
deviation  from  a  normal  and  healthy  act  uf  nutrition  of  any  organ, 
we  must  clearly  vmderstand  the  processes  involved  in  the  normal 
discharge  of  its  functions,  and  the  anatomical  and  histological  facts 
bearing  on  that  act  of  nutrition,  from  its  incipient  stage  to  its  com- 
pletion. To  no  physiological  process  does  this  rule  apply  more  closely 
than  to  the  deviations  commonly  met  with  in  the  menstimal  act  of 
ovulation.  Perhaps  the  most  perfect  example  of  a  nutritive  process, 
elaborated  through  the  healthful  interchange  uf  function,  on  the 
side  of  the  circulating  current  on  the  one  hand,  and  the  tissues  and 
the  nerve  elements  on  the  other,  is  offered  in  the  completion  and 
perfection  of  the  act  of  ovulation. 

At  a  certain  period  of  female  life,  varying  generally  from  the 
twelfth  year  to  the  seventeenth,  known  as  that  of  piuberty,  a 
sanguineous  excretion  occurs  from  the  uterus. 

I  have,  however,  known  several  instances  of  menstniatiou  occurring  from 
the  eitrhth  to  the  tenth  vear,     Barnes  has  recoi'ded  a  case  of  a  girl  aijed 


30  DISEASES   OF   WOMEN. 

eleven,  in  whicli  the  catamenia  commenced  at  sixteen  months  and  continued 
regularly.  Mengus  has  reported  regular  menstruation  in  a  child  twenty- 
three  months  old.  A  case  of  menstruation  on  the  second  day  after  birth  has 
been  recorded  by  Thum.  The  discharge  was  sticky,  and  oozed  from  the 
vagina.  On  the  third  day  of  its  appearance  from  one  drachm  and  a  half  to 
two  drachms  of  bloody  mucus  passed,  the  flow  disappearing  on  the  fifth  day.* 

Precocious  Sexual  Development. 

In  an  interesting  communication  by  Eoger  Willianis,t  in  reviewing  the 
subject  of  precocious  sexual  development,  he  gives  interesting  statistics  bear- 
ing upon  the  first  appearance  of  menstruation.  Tilt  places  the  average  age 
of  this  in  English  girls  at  14*92  years,  and  Emmet  for  American  at  14*23. 
In  the  northern  latitudes  puberty  is  delayed,  in  the  Esquimaux  Avomen,  for 
example,  as  far  as  the  twenty-third  year.  He  adduces  evidence  to  show  that 
sexual  precocity  is  occasionally  associated  with  the  development  of  morbid 
growths,  a  number  of  these  occurring  in  the  ovaries,  several  being  of  the 
sarcomatous  type.  Whereas  girls  have  been  known  to  conceive  at  eight 
years  of  age,  the  earliest  age  at  which  boys  have  proved  virile  is  thirteen 
years.  Statistics  show  that  precocious  development  is  more  frequent  in  the 
lower  races  of  mankind,  and  that  it  lessens  Avith  the  evolution  of  the  race  and 
the  advance  of  civilizing  influences.  Williams  classifies  the  different  types  of 
sexual  precocity  as  follows  : — 

{a)  Menstruation  appearing  prior  to  other  signs  of  sexual  evolution. 
(6)  Precocious  menstruation  with  the  early  appearance  of  other  signs  of 
puberty. 

(c)  Sex  manifestations  Avithont  menstruation. 
{d)  Early  conception  and  pregnancy. 
(e)  Sexual  precocity  with  intra-abdominal  tumour. 

He  records  a  number  of  cases  in  which  menstruation  began  either  at  or 
shortly  after  birth,  and  several  others  from  birth  to  the  sixth  month.  Alto- 
gether he  notes  fifty-nine  authentic  cases  of  precocious  development  before 
the  seventh  year,  and  eleven  cases  in  Avhich  the  precocious  development  was 
associated  with  intra-abdominal  tumour. 

With  Gelston  Atkins,  of  Cork,  many  years  since,  I  induced  labour  on  the 
250th  day  in  a  girl  of  twelve  years  of  age.  She  Avas  delicately  formed,  and 
the  pelvis  AA'as  narrow ;  the  forceps  had  to  be  used.  The  child  survived  only 
a  short  time.  The  yoimg  mother,  who  was  never  told  what  was  the  nature 
of  her  '  tumour,'  Avas  kept  under  chloroform  from  the  time  labour  set  in ; 
the  milk  Avas  suppressed  with  belladonna,  and,  so  far  as  I  know,  she  ncA'^er 
discovered  the  nature  of  the  operation  on  her. 

This  menstrual  flow  is  an  outward  and  visible  sign  of  the  com- 
pletion of  the  ovarian  function  of  ovulation,  or  the  full  development 
of  a  Graafian  follicle,   its  rupture,  and   the  escape  of    the  ovum. 

*  Ann.  Univ.  Med.  Set.,  vol  ii.,  1895. 
+  Brit.  Gyn.  Jour.,  May,  1902. 


ANATOMICAL  ANL   CLINICAL.  ?,\ 


Attendant  on  the  first  appearance  of  this  catamenial  flow,  changes 
appear  in  the  mental  and  physical  nature  of  the  girl  :  it  is  the 
springtime  of  her  existence  ;  and  her  whole  system  participates  in 
the  budding  forth  of  her  sexual  life.  There  is  a  hyperemia  of  her 
sexual  and  mammary  organs.  Local  congestions  may  occur  in  the 
ovaries,  uterus  and  rectum ;  remote  excitations  in  (jther  organs,  as 
the  brain,  heart,  and  lungs ;  reflex  disturbances,  having  their  origin 
in  the  ovaries,  and  irritation  of  the  ovarian  nerves.  This  is  the 
period  of  adolescence  when  the  mental  side  of  the  woman  imper- 
ceptibly changes,  and  temperament  and  character  are  more  clearly 
pronounced.  It  is  during  these  years  of  advancing  girlhood  that 
any  manifestations  (jf  morbid  mentalization  have  to  be  so  carefully 
combated. 

The  recurring  hypera^mia  of  ovary  and  uterus,  with  the  associated 
vascular  and  nervous  disturbances,  continues  for  some  thirty  or 
forty  years  of  the  woman's  life — her  summei-.  And  now  we 
approach  the  critical  autumn  time,  when  this  fertilizing  process 
begins  to  wane,  and  gradually  ceases  altogether — the  period  of  the 
menopause,  from  forty-five  to  fifty,  or  thereabouts,  when  again  we 
tind  her  subject  to  local  and  remote  congestions,  cerebral  afiections, 
vicarious  haemorrhages  from  various  organs,  cardiac  complications ; 
at  the  same  time  occur  exaggerated  reflex  disturbances  and  nervous 
'  discharging  lesions.'  These  accompany  that  '  change  of  life "  * 
during  which  are  developed  those  traits  of  womanhood  which  stamp 
with  peculiar  and  characteristic  features  the  period  antecerlent  to 
the  winter  of  old  age.  It  is  not,  however,  so  much  to  the  change  in 
the  uterine  mucous  membrane,  and  the  periodical  hyperaemia  of  the 
uterine  tissues,  with  the  consequent  flow  of  blood,  that  we  are  to 
look  for  an  explanation  of  these  phases  and  phenomena.  It  is  to 
the  antecedent  act  of  ovulation.  True,  a  woman  may  menstruate 
(in  so  far  as  a  mere  periodical  flow  is  concerned)  without  ovaries, 
but  then  it  is  most  probably  the  mere  perpetuation  of  a  habit.  As 
ft.  physiological  act  it  has  lost  its  prime  significance.  It  is  on  the 
ovaries  rather  than  on  the  uterus  that  the  gynaecologist  has  to 
concentrate  his  attention,  in  investigating  the  normal,  and  in  treat- 
ing the  abnormal,  menstrual  molimen.  We  do  not  find  any  accurate 
explanation  of  many  of  the  phenomena  of  menstrual  life.  There  is 
a  something  in  these  not  to  be  explained  by  any  anatomical  or 
physiological  facts  connected  with  ovulation.  The  effect  of  its 
mysterious  influence  on  the  entii-e  being  of  the  woman  may  not  be 
*  See  remarks  ou  the  climacteric. 


32  DISEASES  OF   WOMEN. 


measured  by  any  descriptive  language.  The  explanation  is  not  in 
the  swollen  and  sensitive  ovary,  nor  in  any  changes  that  occur  in 
the  parenchyma,  in  the  maturation  and  rupture  of  the  Graafian 
follicle,  in  the  accompanying  congestion  of  the  Fallopian  tube,  nor 
yet  in  the  swelling,  proliferation,  and  disintegration  of  the  epithelium 
of  the  uterine  mucous  membrane. 

This  strange  coincidence,  of  a  mental  and  physical  state  being 
closely  dependent  upon  the  healthful  discharge  of  the  function  of  a 
single  organ,  is  best  recognized  when  we  watch  the  consequences  of 
perverted  action,  or  of  any  arrest  or  suppression  of  the  ovarian 
function.  '  The  essential  thing,'  as  Shroeder  says,  '  is  the  discharge 
of  the  ovum  ;  '  the  escape  of  blood  from  the  mucous  membrane  is  an 
accessory  occurrence  which  is,  perhaps,  only  the  indication  of  the 
retrograde  metamorphosis  of  that  membrane.  Conception  may 
occur  while  the  external  evidence  of  ovulation  is  absent,  as  we  have 
seen  that  the  menstrual  flow  may  periodically  appear  when  the 
ovaries  are  removed.  The  congestion  of  the  ovaries  and  other 
genital  organs  may  take  place  with  the  discharge  of  the  ovum, 
while  there  may  be  no  laceration  of  the  uterine  vessels,  and  the 
usual  escape  of  the  disintegrated  mucous  membrane  may  not  follow. 
From  these  brief  remarks  we  can  infer  how  imjoortant  to  the  health 
and  well-being  of  the  woman  is  the  due  performance  of  the  ovarian 
function.  Though  we  may  not  regard  the  uterine  changes  and  flow 
as  of  the  same  essential  significance  as  those  taking  place  in  the 
ovary,  yet,  remembering  the  hypersemic  condition  of,  and  the  local 
determination  of  blood  to,  all  the  genital  organs  at  the  time  of  men- 
struation, we  can  comprehend  how  serious  may  be  the  consequences  of 
a  partial  or  complete  suppression  of  this  escape  of  blood  from  the 
uterus,  the  arrest  of  the  normal  process  of  disintegration  and  ex- 
foliation of  the  uterine  mucous  membrane,  and  the  resulting  reten- 
tion in  the  blood  of  the  abnormal  elements  of  excretion. 


Senile  Changes  in  the  Ovaries.* 

According  to  Otroschkevitch,  the  lessening  of  both  ovaries  in  old  age  arises 
in  connection  with  increased  growth  of  fibrous  connective  tissue  and  the  pre- 
dominance of  this  over  the  degenerating  folHcles.  The  disappearance  of  the 
cpithefium  covering  the  surface  of  the  ovaries  is  a  true  change  in  the  senile 
ovaries.  The  desiccation  of  mature,  and  the  wholesale  degeneration  of  the 
primordial,  follicles  are  important  factors  in  the  change  of  the  ovary  of 
the  aged.     There  is  hyaline  degeneration  of  the  arteries  and  fibrous  tissue 

*  Vratoh,  1896,  No.  o. 


AXATOMICAL   AXD   CLISICAL.  38 


advancing  with   the   age.     Deficient  nutrition  of  the  ovary  leads  to  fatty 
degeneration  of  the  cellular  tissue. 

Menstruation  generally  occurs  from  puberty  to  the  ages  of  forty- 
five  or  fifty,  every  twenty-eight  days  or  at  a  longer  interval  (quite 
compatible  with  health).  The  discharge  lasts  from  three  to  seven 
days,  or  longer.  It  consists  of  blood  and  disintegrated  debris  of 
uterine  mucous  membrane,  the  quantity  of  which  varies  with 
the  duration  of  the  flow.  It  is  influenced  by  climate,  tempera- 
ment, coitus,  haljits  and  rank  of  life,  temperature,  blood-states 
(as  the  exanthemata,  phthisis,  Bright's  disease,  chlorosis,  antemia, 
leuksemia),*  mental  influences  (as  depression,  shock,  hysterical  con- 
dition, the  eSects  on  the  mind  of  illicit  intercourse  and  seduction)  ; 
local  disorders  of  the  genital  organs  and  rectum  (as  fibroid  develop- 
ments, uterine  version  and  flexion,  hyperplastic  states  of  the  uterus)  ; 
morbid  growth  of,  or  abnormalities  in,  the  development  and  position  of 
the  ovaries  ;  any  congenital  or  acquired  stenosis  or  atresic  condition 
of  the  genital  canal  from  the  Fallopian  fimbriated  orifice  to  the  vulva. 

For  the  normal  menstrual  act  to  occur  without  any  aberrant 
signs  or  symptoms,  there  must  be  perfect  relation  of  blood-supply, 
both  in  character  and  quantity,  and  healthful  control  of  nervous 
influence,  not  only  on  the  part  of  the  nerves  distributed  to  the 
various  tissues  involved — arterial,  muscular,  cellular — but  on  that 
of  the  central  nervous  system.  Xowhere  is  this  made  more  manifest 
than  in  the  influence  exerted  on  the  ovary  and  uterus  during  mental 
states,  reflex  disturbances,  or  shocks,  which  show  their  immediate 
effects  in  arrested  and  perverted  menstruation.  It  is  outside  the 
scope  of  this  work  to  enter  into  a  detailed  description  of  the  physio- 
logical function  of  ovulation  and  the  associated  process  of  men- 
struation. This  is  more  distinctly  a  portion  of  the  physiological 
course  of  the  student,  and  is  dealt  with  in  a  more  perfect  manner 
in  treatises  on  physiology  than  can  possibly  be  done  in  a  work  of 
this  nature.  It  must  suffice  to  remind  the  reader  of  certain 
anatomical  and  physiological  facts,  connected  with  the  act  of  ovu- 
lation, which  bear  on  some  of  the  clinical  phenomena  of  menstru- 
ation, and  the  deviations  from  its  normal  occurrence,  which  the 
gynaecologist  is  called  upon  to  treat. 

*  While  the  psychological  importance  of  the  establishment  of  the  menstrual 
function  in  women  who  are  mentally  affected  cannot  be  overlooked,  the  fact 
that  the  suppression  of  menstruation  is  often  the  consequence  of  the  abnormal 
psychical  state,  and  not  its  cause,  has  to  be  remembered.  I  refer  to  these 
psychological  correlations  further  on  in  the  chapters  dealing  with  the  correla- 
tion of  sexual  functions  and  insanity,  and  the  operation  of  8alpingo-o<">phorectomy. 

D 


34  DISEASES   OF   WOMEN. 

Various  Views  on  the  Physiology  of  Ovulation  and  Menstruation. 

Landois  and  Stirling,  in  the  '  Text-book  on  Human  Physiologj','  adhere  to 
the  views  of  Kundrat  and  Engelmann,  that  there  is  a  fatty  degeneration  of 
the  superficial  layers  of  the  mucosa,  the  new  mucous  membrane  being 
developed  from  these  deep  layers  when  the  period  is  over. 

With  regard  to  the  relation  home  by  the  ovaries  in  the  menstrual  function 
to  both  the  Fallopian  tubes  and  uterus,  the  following  is  a  summary  of  these 
authors'  views. 

1.  The  partial  contraction  of  the   muscular  tunic  of  the  Fallopian  tube 

assists  in  the  propulsion  of  the  ovum. 

2.  The  bloodvessels  of  the  Fallopian  tubes  are  then  injected,  possibly  by 

the  constriction  of  the  vessels  in  the  broad  ligaments,  by  their  non- 
striated  muscular  elements.     (Rouget.) 

3.  Pfiiiger's   view  is  that   the  physiological  '  freshening  '  of  the  uterine 

mucous  surface  affords  nutriment  to  the  newly  received  ovum. 

4.  Reichert's  view  (and  that  of  Engelmann  and  Williams)  is  that  the  change 

in  the  uterine  mucous  membrane  is  a  sympathetic  one,  resulting  in 
sponginess,  vascularity,  and  swelling.     Thus  is  formed  a  memhrana 
decidua  menstrualis,  which  is  not  disintegrated  unless  the  ovum  be 
fertilized,  and  hence  there  is  no  external  discharge,  this  negative  sign 
being  the  proof  of  fertihzation  under  normal  conditions  of  health. 
The  occun"ence  of  ovulation  and  menstruation  may  not  be  synchro- 
nous, and  hence  there  may  be  ovulation  without  menstruation,  and 
vice  versa. 
In  connection  with  the  anatomical  process  of  ovulation,  the  views  of  Paul 
Strassman  *  are   of  interest.     I  am   indebted   for  the  translation  to  John 
Taylor  and  Frederick  Edge.f 

Ovulation  can  under  certain  circumstances  take  place  before  menstruation, 
the  occasional  occun-ence  of  pregnancy  in  a  girl  who  has  never  menstruated 
proving  this.  The  spontaneously  burst  menstruation  follicle  is  a  bigger 
structure  than  that  of  the  unburst  follicle  seen  in  ovaries  removed  by  lapa- 
rotomy. The  translators  have  seen  many  follicles  of  15  mm.  in  diameter. 
Sexual  impulse  and  cohabitation  can  only  be  regarded  as  having  a  possible 
or  questionable  influence  on  ovulation.  The  ripening  of  the  ovum  and 
menstruation  are  always  completely  ind'ependent  of  sexual  congress  (Bischoff, 
Negi'ier,  Raciborsky,  Bouchet).  Rupture  of  a  follicle,  and  its  dehiscence, 
may  be  accelerated  by  connection.  Each  menstruation  is  the  expression  of 
an  ovulation.  The  uterus  being  dependent  upon  the  ovaries  for  development 
and  growth,  it  is  only  a  step  to  conclude  that  heightened  activity  of  the  ovary 
calls  forth  a  corresponding  life  expression  of  the  uteiiis.  In  both  this  is 
periodical,  so,  consequently,  is  menstruation.  It  is  a  rhythmic  life  expres- 
sion. Anatomical  examinations  on  the  number  of  corpora  lutea,  contrasted 
with  the  number  of  known  menstruations,  established  the  connection  between 
ovulation  and  menstruation,  a  connection  still  further  established  by  a 
majority  of  post-operative  reports,  which  point  to  the  same  fact.  Disturbances 
*  ArcMv.f.  Gyncik.,  bk.  52,  ch.  1,  1S9G. 
t  Brit.  Gyn.  Jour,,  p.  11,  vol.  xii. 


AXATOJIICAL   AXD   CLIXICAL. 


iu  the  position  and  diseases  of  the  adnexa  may  cause  deviations  from 
the  normal  rhythmic  menstrual  act.  Hence,  intermenstrual  pain  was  ex- 
plained by  Fehling  as  a  normal  ovulation  between  two  menstrual  periods. 
How  common  such  pain  is  every  gynaecologist  is  aware,  and  the  relief  of  this 
symptom,  as  well  as  the  pain  of  ordinary  menstruation,  by  treatment  of  the 
ovaries,  or  their  massage,  is  explained  by  the  consequent  changes  of  the 
relative  position  of  the  adnexa  and  uterus.  A  light  is  thus  thrown  on 
the  different  results  which  may  follow  the  forcible  and  exhaustive  examina- 
tions of  the  adnexa  under  anaesthesia.  Other  authorities,  as  Slavjansky, 
Leopold,  Miranoff,  and  Pfliiger,  regard  ovulation  and  menstruation  as  quite 
independent  events,  menstruation  being,  according  to  these,  a  self-standing 
physiological  phenomena,  and  various  explanations  have  been  advanced  to 
explain  the  cases  where  menstruation  takes  place  without  ovulation.  Leopold 
distinguishes  between  t}^ical  corpora  lutea  and  atypical,  the  latter  arising 
ft'om  unburst  follicles  whose  walls  have  fallen  together  and  only  contain  a 
little  blood  clot.  Taylor  and  Edge  regard  these  latter  corpora  as  pathological. 
and  due  to  their  removal  from  cases  which  had  been  operated  upon,  and  they 
contend  that  evidence  of  the  retention  of  an  ovule  on  the  follicle  is  wanting. 
Leopold  and  Miranoff  adopt  Pflliger's  view  that  the  movement  of  menstruation 
is  due  to  the  steady  growth  of  the  follicles,  or  the  predominating  growth  of 
one  follicle,  a  powerful  blood  congestion  of  the  genitalia  occurring,  followed 
by  menstrual  changes  in  the  uterus,  and  the  secondary  bursting  of  the  follicle. 
Pfliiger,  in  explanation  of  the  periodicity  of  menstruation  without  ovulation, 
says  that  '  menstruation  occurs  without  ovulation  when  no  large  corpus 
luteum  happens  to  be  present,'  and  he  adopts  the  'theory  of  a  dynamic 
equilibrium  of  all  organs,  from  which  it  follows  that  the  ovaries  carrj-  a 
definite  number  of  stimidi  to  the  central  nervous  system  any  day.' 

But,  as  the  translators  observe,  recumng  menstruation  of  a  healthy  woman 
is  recognizable,  that  of  ovulation  is  not ;  nor  is  it  certain  that  the  condition 
of  the  mucous  membrane  of  the  uterus  in  relation  to  expected  conception 
can  be  regarded  as  normal.  They  hold  generally  to  the  view  that  the  shedding 
of  the  ovum  is  periodical,  like  rnenstniation. 

Menstruation,  according  to  Strassman  and  others,  is  not  an  independent 
life  expression  of  the  uterus,  and  the  bursting  of  the  follicle  is  not  due  to 
menstrual  congestion.  Pregnancy  occurs  in  amenorrhcEic  women,  in  children 
who  have  not  menstruated,  exceptionally  in  the  menopause,  and  during 
lactation.  There  is  no  sudden  evolution  of  the  foUicle,  vascular  development 
of  the  ripening  process  going  on  pari  jpassu. 

Other  important  points  which  are  established  in  the  work  quoted  are — 

(1)  That  the  opening  of  the  follicle  occurs  independently  of  menstruation 
(Reichert,  Leukardt,  "Waldeyerj.  Periodical  increase  of  the  ovarian  activity, 
with  swelling  of  the  ovaries  every  fourth  week,  was  noticed  by  Werthe  in  'a 
case  of  hernia  of  the  ovaries.     The  same  fact  was  recorded  by  Englisch. 

(2)  That  the  ovaries  decrease  in  volume  during  menstruation  (Morell- 
LavaUe,  Verdier,  Barnes,  Oldham).  Blood  pressure  is  reduced  in  the  inter- 
menstrual period.  Palpation  of  the  ovaries  (Von  Hoist,  J.  Meyer',  is  easier 
during  menstruation  owing  to  their  swollen  condirion.  Hyrtl  found  a  minute 
ovum  in  the  uiterstitial  portion  of  the  tube  on  the  fourth  day  of  mensh-uation, 
long  after  the  rupture  of  the  foUicle. 


36  DISEASES   OF    W02IEN. 

(3)  It  has-  been  established  (Leopold,  Williams,  His,  Eeichert)  that  a  period 
of  about  two  days  may  be  taken  as  that  generally  occm-ring  between  the 
bm-sting  of  the  follicle  and  menstruation. 

(4)  By  a  series  of  experiments,  and  the  production  of  artificial  ovulation  in 
dogs,  Strassman  claims  to  have  established  that  ovulation  is  the  cause  of  the 
changes  in  the  endometrium  and  genitalia  observed  during  menstruation. 
Such  changes  are  the  consequence  of  excitation  of  the  ovarian  nerves,  causing 
reflex  vaso-motor  excitation  in  the  uterine  arteries,  and  these  nerve,  and 
gangUonic  and  nerve,  irritations  proceed  in  the  duly  provided  paths  (Rohrig). 
The  nerve  supplies  of  the  ovaries  and  the  ganglionic  relations  to  the  vessels 
faA'Our  these  processes. 

(5)  The  period  of  incubation  from  the  rupture  of  the  follicle  until  the 
appearance  of  menstruation  is  the  time  occupied  in  the  development  and 
completion  of  these  physiological  ovario-uterine  changes.  We  find  its 
analogues  in  the  appearance  of  lactation,  and  in  the  pseudo-menstruations 
after  operations. 

As  the  result  of  his  investigations  on  monkeys,  Bland-Sutton  came  to  the 
conclusion  that  the  mucous  membrane  is  not  disintegrated  to  the  extent  pre- 
viously represented,  and  that  only  the  epithelium  is  shed,  while  the  utricular 
glands  are  enlarged,  and  blood  is  discharged  from  the  denuded  epithelial  sur- 
face. Arthur  Johnstone  *  regarded  the  endometrium  above  the  os  internum 
as  a  cytogenic  membrane  and  belonging  to  the  class  of  so-called  adenoid 
tissues,  '  menstruation  being  for  it  what  the  lymph-stream  is  to  the  lymph- 
gland,  or  the  blood  current  to  the  spleen.'  He  gave  as  the  simplest  definition 
of  menstruation,  '  a  periodic  wasting  of  those  corpuscles  that  are  too  old  to 
make  a  placenta.'  The  epithelium  alone  is  shed,  and  the  mucous  membrane 
is  not  disintegrated.  '  The  Fallopian  tube  undergoes  no  structural  change 
during  menstruation.' 

Lawson  Tait,  from  careful  dissections  of  the  ovaries,  noted  the  condition  of  the 
corpora  alba  and  corpora  lutea.  In  all,  the  ovaries  were  practically  destroyed. 
He  came  to  the  conclusion,  from  these  dissections,  that  in  menstruation  we 
are  dealing  with  a  function  associated  with  the  uterus  and  Fallopian  tubes, 
inasmuch  as  menstruation  and  ovulation  were  only  '  coincident '  in  twenty-six 
out  of  the  fifty-one  women ;  in  seventeen  they  were  not  coincident ;  eight 
were  doubtful.  Such  pathological  evidences  do  not  appear  to  me  to  invalidate 
the  clinical  importance  of  other  physiological  facts  that  establish  the  relation- 
ship between  o^^nilation,  at  whatever  time  it  takes  place,  and  the  menstrual 
flow.  Lemiere  explains  such  persistence  of  menstruation  after  removal  of  the 
ovaries  and  tubes  by  an  organic  habit  of  the  nerve-centres  and  uterus,  enabHng 
the  latter  to  discharge  the  function. 

Byron  Eobinson  has  ascribed  the  aberrations  of  the  menstrual  functions 
in  women  to  the  nervous  supplies  of  the  ovaries  and  uterus,  arising  in  what 
he  terms  '  the  abdominal  brain,'  and  the  renal  and  abdominal  plexuses  of  the 
sympathetic  nerve.  This  source  of  nerve-disturbance  is  in  a  condition  of 
hyper-excitation  at  certain  times,  especiallj''  during  the  menopause.  During 
this  time  the  woman  suffers  from  perverted  nutrition  in  her  sexual  organs, 
and  slight  peripheral  excitations  are  sufficient  to  originate  reflex  disturbances. 

*  Proceedings  of  the  British  Gynsecological  Society,  June  23,  1886. 


ANATOMICAL    A\/>    Cf.lMCAL.  \M 


The  obvious  deduction  to  be  drawn  from  these  physiological  coiTelations  is, 
that  wliile  soothing  anj'  local  painful  and  irritating  states  in  the  organs  within 
the  pelvis,  we  have  often  to  look  outside  these  to  the  general  nervous  system 
for  collateral  visceral  neuroses  elsewhere  during  the  critical  times  of  pubert}- 
and  the  climacteric. 

Martin  of  Birmingham  insists  on  the  dependence  of  menstruation  on  a  special 
nervous  supply,  issuing  from  a  special  nerve-centre  in  the  lumbar  portion  of 
the  S[iinal  cord,  the  arrest  of  the  function  after  oophorectomy  depending  upon 
section  of  tlie  menstrual  ner\'e.  He  behoves  that  either  the  pelvic  splanchnics 
or  the  ovarian  plexus  are  the  roads  through  which  the  menstrual  impulses 
travel  to  the  uterus.  He  urges  that  all  the  physiological  facts  connected  witli 
menstruation  point  to  this  control  by  a  special  nerve-centre. 

'  We  thus  see  that  during  the  period  between  the  follicular  rupture 
and  the  appearance  of  menstruation,  momentous  changes  are  occur- 
ring in  the  ovarian  and  uterine  vascular  connections.*  An  impor- 
tant part  is  played  not  only  in  the  rhythmical  occurrence  of  the  act 
of  ovulation  and  its  menstrual  attendant,  but  also  in  its  character 
and  quantity,  as  well  as  in  the  nervous  phenomena  attendant 
upon  it,  by  the  vasomotor  supplies  of  the  genitalia  through  the 
renal,  abdominal,  and  pehdc  plexus.  The  normal  nutritive  balance 
maintained  during  the  interval  is  disturbed  before  the  onset,  and, 
as  a  consequence,  a  perverted  metabolism  is  induced  in  the  internal 
genitalia.  This  culminates  in  the  disintegrating  pi'ocess  with  its 
associated  discharge  from  the  uterine  endometrium.  The  katabolic 
activity  is  provided  for  through  the  free  supply  of  blood  from  the 
ovarian  and  uterine  arteries,  the  large  uterine  and  ovarian  veins, 
the  larger  outlets  in  the  broad  ligaments,  and  the  ramifying 
plexuses  of  lymphatics,  which  make  their  way  to  the  pelvic,  lumbar, 
and  inguinal  glands.  The  generative  forces  acting  after  fertilization 
of  the  ovum,  or  in  the  maturation  of  the  follicle,  and  the  anabolic 
manifestations  occurring  prior  to  its  maturation,  are  doubtless,  as 
many  believe,  under  the  control  of  a  special  cord-centre  in  the 
lumbar  region — the  generative  or  sexual  brain ;  but  the  clinical 
facts  are  numerous  which  point  to  the  inhibitory  influence  exerted 
by  the  mind  and  the  various  psychical  excitations  on  both  the  con- 
structive and  destructive  forces  at  work  in  the  evolution  and  involu- 
tion of  the  entire  process.' 

'  Menstruation  has  thus,  for  clinical  purposes,  to  be  regarded  in 
the  light  of  a  complex  train  of  cyclical  physiological  phenomena, 
involving  various  structures  in  distinct  but  ultimately  correlated 
parts,  manifesting  themselves  in  rhythmical  regularity  and  sequence. 

*  From  'Practical  Points  in  Gynjecology,'  by  the  Author,  3rd  edition,  1902. 


38  DISEASES  OF   WOMEN. 


This  cyclical  and  rhythmical  sequence  is  subject  to  interferences 
which  have  their  commencement  at  times  within  the  organ  in  which 
these  processes  originate,  or  are  determined  by  extragenital  abnor- 
mal conditions,  present  either  in  the  nervous  or  circulatory  systems, 
or  the  various  organic  changes  which  have  taken  place  in  such 
viscera  as  the  brain,  heart,  liver,  spleen,  or  kidney.' 


Pseudo-menstruation. 

These  explanations  of  pseudo-menstruation  are  given  : — 
In  the  case  of  large  tumours  the  overfilling  of  the  vessels  of  the  pedicle 
(Olshausen)  leads  to  congestion  and  bleeding.  The  weakness  of  the  heart 
action  and  the  reduction  of  the  intra-abdominal  pressure  may  assist  this  over- 
flowing of  the  uterine  vessels.  The  view  of  Issmer  and  Veit  is,  that  by  the 
removal  of  the  ovary  with  a  ripe  follicle  we  practically  induce  the  menstrual 
act,  and  the  incubative  period  explains  the  delay  in  appearance. 

All  these  arguments  support  the  view  always  advocated  in  pre- 
vious editions  of  this  work,  and  reiterated  in  the  present,  that  from 
the  ovary,  through  its  physiological  function  of  ovulation,  is  issued 
the  mandate  for  the  visible  act  of  menstruation  to  commence,  and 
that  it  is  to  the  ovary  rather  than  to  the  uterus  we  have  to  look 
for  the  explanation  of  the  various  physiological  and  clinical  pheno- 
mena which  at  puberty,  in  adult  life,  and  at  the  menopause,  are 
centred  in  the  appearance  of  the  menstrual  act. 

Transplantation  of  the  Ovaries. 

So  far  back  as  1899  J.  F.  McCome  came  to  the  following  conclusions  from 
a  series  of  experiments  on  thirty  animals : — 

(1)  That  contact  between  ovary  and  tube  is  not  essential  for  conception. 

(2)  That  ovaries  grafted  from  one  part  of  an  animal  to  another  part  of  it 
continue  to  grow  and  functionate,  so  that  pregnancy  can  and  does  occur. 

(3)  That  an  ovary  grafted  from  one  animal  to  another  of  the  same  species 
continues  to  functionate,  so  that  pregnancy  can  occur,  (4)  That  ovaries 
grafted  from  one  species  to  another  continue  to  functionate,  and  appear 
to  prevent  post  castration  atrophy  of  the  tubes  and  uterus.  (5)  The  best 
results  are  obtained  when  the  raw  surface  of  a  transplanted  ovary  is  sewn  to 
a  denuded  surface.* 

In  1901  Knauer,  Eoxas,  and  Lookaschevitsch  f  arrived  at  similar  con- 
clusions. The  former  asserted  that  complete  ovulation  might  occur,  and 
conception  and  pregnancy,  after  transplantation.     In  sheep  the  transplanted 

*  Amer.  Jour.  Obs.,  Aug.,  1899. 

t  ArcMv.  di  Ost.  e  Gin.,  Jane,  1901 ;   Vratch,  1901,  No.  29. 


ANATOMICAL  AND   CLINICAL.  39 

ovaries  continue  to  prodnco  mature  follicles  and  ova.  The  first  suggestion 
was  that  the  ovary  should  he  planted  in  the  loose  extra-peritoneal  tissue,  or 
introduced  into  the  iielvic  intra-peritoneal  cavity  per  vagina.  In  trans- 
plantation necrosis  is  avoided  by  having  a  small  jiediclo  for  fixation  purposes, 
none  of  the  sutures  being  carried  through  the  ovarian  tissue  proper.  Lookas- 
chevitsch  suggested  that  the  ovaries  should  be  sutured  as  nearly  as  possible 
to  their  places  in  the  broad  ligament.  The  transplantation,  according  to  him, 
is  not,  as  a  rule,  durable,  atrophic  and  degenerative  changes  occurring  in  the 
transplanted  ovaries.  Both  he  and  Eoxas  maintain  that  the  physiological 
efl[ects  of  castration  are  at  least  retarded  by  the  transplantation. 

F.  H.  Martin,  in  July,  1903,  also  arrives  at  the  same  conclusions,  and  that 
menstruation  will  continue,  in  women  and  monkej's,  after  homo-transplanta- 
tion, and  that  conception  has  followed  it  in  women.  Also,  that  ovaries 
transplanted  to  other  than  normal  situations  maintain  their  vitality  and 
functionate.* 


The  Internal  Secretion  of  the  Ovary. 

Curatullo  and  Tarulli  f  have  reviewed  the  entire  question  of  the  influence 
of  oophorectomy  upon  the  metabolic  phenomena  in  the  organism,  as,  for 
example,  on  the  respiratorj'  products,  the  body  weight,  and  the  elimination 
of  phosphates,  and  have  arrived  at  the  conclusion  that  removal  of  the 
ovaries  has  a  marked  influence  on  metabolic  phenomena.  The  greatest 
effect  is  on  the  elimination  of  phosphorus,  which  is  diminished ;  the  elimina- 
tion of  carbonic  acid,  and  the  absorption  of  oxygen  by  respiration,  diminish 
up  to  a  certain  point,  and  then  remain  in  the  same  proportion  without 
further  change.  The  body  weight  is  increased.  The  diminution  of  phos- 
phates after  oophorectomy  has  suggested  to  Schauta  and  others  this  operation 
with  or  without  removal  of  the  uterus  as  a  cure  for  osteomalacia,  which 
Fehling  has  attributed  to  exalted  ovarian  functional  activity,  and  consequent 
reflex  effects  on  the  vaso-dilators  and  constrictors  of  the  medulla.  There  is 
a  resulting  increase  of  reabsorption  of  the  calcareous  salts,  more  particularly 
of  the  pelvis.  The  disease  is  a  reflex  tropho-neurosis  of  the  skeleton,  having 
its  focus  of  reflexion  in  the  ovary.     The  conclusions  arrived  at  are  : — 

'  The  ovaries  have,  like  other  glands  of  the  system,  according  to  Brown 
Sequard's  general  law,  an  internal  secretion.  This  is  passed  constantly  into 
the  blood,  its  chemical  constitution  being  quite  unknown,  while  its  most  essen- 
tial characteristics  are  those  of  favouring  oxidation  of  organic  phosphorized 
bodies,  of  hydrates  of  carbon,  and  of  fats.  Hence  it  follows  that  (by  removal 
of  the  ovaries  or  absence  of  their  function,  as  before  puberty  and  after  the 
climacteric)  there  ought  to  be,  on  the  one  hand,  a  greater  retention  of  organic 
phosphorus,  and  thus  a  greater  accumulation  of  calcareous  salts  in  the  bones  ; 
and,  on  the  other,  the  well-known  occurrence  of  obesity  following  on  castra- 
tion or  the  menopause.'  X 

*  Chi.  Med.  Bee,  July  13th,  1903. 

t  Annali  di  Obstetricia  Ginecologia,  Oct.,  1896  ;  Brit.  Gyn.  Jour.,  Feb.,  1897. 

X  Brit.  Gyn.  Jour.,  Feb.,  1897. 


■40 


DISEASES   OF   VTOMEN. 


It  is  not  to  be  forgotten  that  the  uterus  is  capable  of  contraction 
under  the   influence   of    sexual    intercourse,   and    the    expulsion 

of  some  of  the  uterine 
mucus  may  thus  take 
place.  This  reflex  con- 
traction may  be  asso- 
ciated with  corresponding 
contraction  of  the  Fal- 
lopian tubes.  This  has 
an  important  bearing  on 
the  question  of  sterility 
and  the  effect  of  exces- 
sive or  imprudent  inter- 
course, which  may  thus 
cause  loosening  or  expul- 
sion of  the  ovum. 

A  married  lady,  under  cer- 
tain influences,  had  violent 
uterine  contractions,  gener- 
ally associated  with  the  cata- 
menial  periods,  in  which  the 
vagina  participated.  The 
uterus  was  driven  down  to 
the  vulvar  orifice,  and  it  was 
difficult  to  keep  a  specuhim 
in  the  vagina.  A  digital  examination  was  sufficient  to  bring  on  these  con- 
tractions. Fearing  that  there  might  have  been  some  intra-uterine  polyixis  or 
fibroid,  I  dilated  the  uterus  and  explored  the  cavity,  but  there  was  no  intra- 
uterine growth.  She  suffered  from  an  old  laceration  of  the  cervix  and  some 
corporeal  endometritis  and  menorrhagia.  Free  application  of  nitric  acid  to 
the  uterine  cavity  materially  benefited  her,  and  relieved  the  spasms. 

The  Rectum. — In  practice,  the  close  sympathy  that  exists  between 
the  uterus  and  the  rectum  is  often  overlooked.  I  enter  into  the 
practical  bearings  of  this  sympathy  on  rectal  operations  in  the 
chapter  on  the  'Rectum.'  The  habitual  neglect  of  the  lower  bowel, 
which  is  frequently  met  with  in  women,  is  the  cause  not  only  of 
constitutional,  but  also  of  many  local  disorders.  Various  dyspeptic 
troubles — headache,  flatulent  pain,  functional  heart  palpitations, 
hemorrhoids — follow  from  a  congested  portal  system.  A  congested, 
htemorrhagic,  or  an  unnaturally  dry,  condition  of  the  mucous 
membrane  is  constantly  found  as  the  companion  of  different  vaginal 
and  uterine  disorders.     One  organ  reacts  on  the   other,    and  the 


Fig.  24. — ^Uterus  dueixg  Mexstkuatiox. 
(Gallakd.) 

A,  mucous  of  the  neck ;  B,  mucous  of  the  body ; 
C,  thickness  of  the  mucous;  D,  tissue 
proper;  E,  thinning  of  the  neck  and  at  the 
Fallopian  tubes. 


ANATOMICAL  AXD   CLINICAL.  41 

recognized  difficulty  iii  curing  any  rectal  affection  while  a  uterin*- 
diseased  state  continues,  renders  it  imperative  to  relieve  the  former 
before  we  can  hope  permanently  to  benefit  the  latter.  This  is 
especially  true  of  fissure,  strictured  states,  fistula,  ulcers,  pruritus. 
But  perhaps  the  complication  most  commonly  met  with  is  haemor- 
rhoids, both  external  and  internal.  These  are  more  distressing  when 
there  exists  at  the  same  time  any  version  or  flexion  of  the  uterus, 
particularly  retroversion,  the  uterine  pressure  aggravating  the 
rectal  pain  and  discomfort.  A  rectocele  associated  with  uterine 
prolapse  or  injury  to  the  perineal  body  is  a  not  uncommon  compli- 
cation. The  rectum  is  encroached  on,  and  the  act  of  defsecation 
is  intei-fered  with,  in  pelvic  peritonitis  with  effusion,  uterine  fibroids, 
and  by  various  accumulations  in  Douglas'  pouch.  In  making  our 
first  thorough  pehdc  examination,  having  previously  by  an  enema 
emptied  the  rectum,  we  often  gain  our  most  important  information 
by  a  careful  rectal  exploration.  (See  '  First  Steps  in  Examination," 
and  '  Remarts  on  Eectal  Exploration  in  Children.) 

The  Appendix  Caeci. — So  frequently  is  the  appendix  involved 
in  diseases  of  the  adnexa,  and  so  commonly  lias  it  to  be  removed  in 
operations  on  the  pelvic  viscera,  that  its  positions  in  the  abdomen 
have  to  be  carefully  studied.  Cunningham  gives  three  principal 
directions  in  which  it  runs: — '(1)  Over  the  brim  into  the  pelvis. 
("2)  Upwards  behind  the  caecum.  (3)  Upwards  and  inwards  to- 
wards the  spleen,"  In  the  first  situation  it  hangs  over  the  pelvic 
brim ;  in  the  second,  the  caecum  must  be  turned  upwards  in  order 
to  expose  it;  and  in  the  third,  the  end  of  the  ilium  and  the  mesentery 
must  be  raised  in  order  to  display  it.  (Cunningham,  loc.  cit.)  I 
myself  have  recorded  a  case  in  which  it  was  attached  to  the  bottom 
of  the  pelvis,  and  another  in  which  it  was  attached  to  an  ovarian 
cyst  reaching  to  the  iliac  fossa  of  tJie  Ifft  sidi^. 

Appendical  Complications.* — The  relation  of  appendicitis  to  tubal 
inflammation  and  infection  of  the  adnexa  has  not  had  accorded  to 
it  the  importance  that  it  deserves.  Erom  many  recent  observations 
two  things  are  evident.  First,  that  infection  of  the  adnexa  results 
in  a  fairly  large  proportion  of  cases  from  a  diseased  appendix. 
Archibald  Maclarenf  has  published  an  interesting  paper  on  this 
topic,  and  Lapthorn  Smith  has  reported  cases  of  ectopic  gestation  in 
which  the  gestation  sac  was  distinctly  infected  through  the  appendix. 

*  See  also  chapters  on  Pelvic  Inflammation,  Myomata,  and  Fallopian  Tubes 
for  further  references  to  Appendical  Complications. 
t  Amer.  Jour,  of  Ohstet.,  Jnly,  1900. 


42  DISEASES   OF    WOMEN. 


Some  years  since  I  attended  a  case  in  which  the  differentiation  of  ap- 
pendicitis from  salpingitis  was  difficult,  the  earlier  symptoms  being  those  of 
salpingitis,  with  an  adnexal  tumom-  at  the  right  side.  These  were,  however, 
quickly  masked  by  those  of  appendicitis.  I  urged  coeliotomy,  but  consent 
would  not  be  given.  When  the  surgeon  who  had  charge  of  the  case  did 
finally  operate,  it  was  found  that  the  bowel  was  ruptured,  and  there  were  ■ 
several  hard  concretions  in  the  appendix. 

The  second  jDoint  with  regard  to  the  appendix  is,  the  danger  of 
post-operative  adhesions  with  involvement  of  the  appendix  causing 
subsequent  pain  and  disappointment  to  the  patient.  Noble  has 
shown  the  large  number  of  cases  in  which  appendical  trouble  com- 
plicated the  oophorectomy.  The  lesson  we  learn  is,  the  need  for 
careful  disposal  of  the  appendix  in  every  case  of  salpingo-oophorec- 
tomy  or  ovarian  resection,  with  the  need  for  complete  covering  of 
the  pedicle  with  peritoneum,  and  early  movement  of  the  bowel  after 
operation. 

There  is  the  not  uncommon  yet  most  serious  error  of  mistaking 
the  earlier  symptoms  of  ajjpendicitis  for  inflammation  of  the  adnexa 
and  pelvic  peritonitis.  I  have  seen  some  fatal  errors  arising  from 
this  mistake,  with  the  consequence  that  perforation  occurred  from 
a  fulminating  appendicitis  before  any  operation  was  proposed.  At 
the  same  time  it  is  well  to  bear  in  mind  the  possible  occurrence  of 
some  form  of  ovaritis  or  salpingitis,  side  by  side  with  the  appendi- 
cital  inflammation  (Plate  I.). 

Case  of  Complete  Absence  of  the  Internal  Genitalia  *  discovered 
through  an  Attack  of  Appendicitis — Faecal  Fistula — Recovery. 

The  following  case,  in  which  an  appendical  abscess  was  unexpectedly  dis- 
covered by  cceliotomy,  is  of  considerable  interest.  It  exemplifies  the  great 
importance  of  rectal  examination  for  disease  of  the  pelvic  viscera  in  young 
children,  as  also  the  obscure  nature  of  the  symptoms  which  may  usher  in  or 
attend  upon  an  appendical  attack  or  abscess.  Apart  from  this,  it  shows  how 
mistaken  we  may  be  in  our  diagnosis  even  after  a  most  careful  examination 
under  ansesthesia.  Again,  it  proves  how  rapidly  a  fsecal  fistula  may  close. 
The  position  of  the  appendix  also,  and  its  attachment  at  the  bottom  of  the 
pelvis,  was  peculiar,  and  the  case  is  also  worthy  of  record  from  the  complete 
absence  of  the  internal  genitalia. 

An  active,  healthy  child  had  had  no  previous  illness,  when  she  was 
suddenly  seized  one  afternoon  with  abdominal  pain,  which  lasted  for  the 
entire  night.  Treatment  did  not  relieve  the  attacks  of  colicky  pain  and 
pyrexia  which  followed.  I  saw  her  for  the  first  time  ten  days  after  the  first 
symptoms  set  in,  and  examined  her  under  an  anaesthetic .     By  the  vagina, 

*  For  other  examples  of  absence  of  the  genitalia,  see  chapter  on  '  Atresia  of 
the  Vagina.' 


1 


PLATE    I. 


Appendix.  Fallopian  Tube  and  Cystic  Ovaky.     (Althoi!.) 

The  removed  concretion  is  the  natural  size.     The  second  is  seen  filling  the 
Innien  of  the  appendix.     Kecovery.     (See  page  43.) 


PLATE   11. 


An  Ovakian  Cyst  avitii  Oriental  Adhesions  above  and  an  Adheiient 
Veejiifokm  Appendix  bellcsv.     (Kelly.) 

[To  face  p.  42. 


AXATOMICAL   AXD    CLINICAL.  43 

bi-manually,  both  supra-pubically  and  through  the  rectum,  no  uterus  could 
be  detected,  nor  any  evidence  of  adnesa.  This  was  made  quite  clear  by  the 
most  careM  recto- vesical  examination.  Through  the  rectum,  above  the 
vagina  (not  so  well  felt  through  the  latter),  a  soft  tumour  or  mass  could  be 
discovered,  rather  sausage-shaped.  I  could  not  decide  what  the  nature  of 
the  tumour  was,  but  thought  it  might  be  a  soft  dermoid  cyst  of  a  rudimentary' 
ovary.  I  advised  abdominal  exploration,  and  on  the  28th  I  opened  the 
abdomen.  I  found  the  bowel  generally  in  an  injected  and  congested  condition, 
with  some  soft  peritoneal  adhesions  here  and  there.  These  were  more  par- 
ticularly apparent  at  the  left  side  and  in  the  neighbourhood  of  the  sigmoid, 
in  which  was  a  faecal  mass  doubled  over  the  rectum,  evidently  that  which  I 
had  felt  through  the  bowel.  No  uterus  or  adnesa  was  discoverable.  Thie 
appendix  was  carried,  dov:n  to  the  hottora  of  tlie  'pelvis,  where  it  luas  fixed  by 
adhesions.  It  was  about  six  inches  in  length.  On  rapturing  the  adhesions 
which  attached  it  some  pus  escaped.  The  appendix  was  removed,  and  the 
infected  portion  of  the  pelvis  having  been  cleansed  with  formalin  solution, 
the  abdomen  was  closed,  an  iodoform  drain  being  left.  Things  went  on  fau'ly 
well  until  the  fifth  day  after  operation ;  the  long  drainage  gauze  having  been 
removed  and  a  shorter  inserted.  On  this  day  some  fsecal  discharge  was  per- 
ceived coming  from  the  drainage  opening  in  the  abdominal  wound.  The 
opening  was  carefully  cleansed  and  kept  patent,  but  was  not  otherwise  dis- 
turbed. On  the  eighth  day  after  operation  the  bowels  were  acting  satisfactorily 
with  enema,  the  wound  was  healing,  and  there  was  neither  ftecal  matter  nor 
discharge.  From  this  time  the  progress  of  the  case  was  uninterrupted,  with 
the  exception  of  an  attack  of  cystitis,  from  which  she  perfectly  recovered. 

Adherent  and  Enlarged  Appendix  containing  Concretions 
complicating  Cystic  Ovary. 

In  a  recent  oophorectomy  I  found  the  right  cystic  ovary  had  formed  for  its 
entire  length  a  firm  union  with  the  appendix.  The  latter,  gi^eatly  enlarged, 
and  marked  by  constrictions,  was  removed,  separately  from  the  ovary,  and  in 
it  were  found  two  hard,  smooth  concretions,  the  size  of  beans.  The  com- 
plication explained  the  associated  abdominal  and  pelvic  pains  which  had  pre- 
viously afiected  the  health  of  the  patient  for  some  years  before  operation 
(Plate  I.) 

The  Urinary  Organs  —  Difficulties  in  Diagnosis, — The  gynse- 
cological  student  must  have  a  sound  practical  knowledge  of  the 
anatomy  of  the  kidneys,  ureter,  and  bladder.  The  more  gynfeco- 
logical  surgery  advances  the  more  we  see  the  importance  of  such 
an  accurate  acquaintance  with  the  position  and  relation  of  these 
\-iscera.  Various  morbid  states  of  the  kidney,  such  as  movable 
kidney,  hydronephrosis,  pyonephrosis,  perinephritic  abscess,  and 
cystic  disease,  are  liable  to  be  mistaken  or  overlooked  in  diagnosis. 
It  is  a  matter  of  common  occurrence  for  renal  disease  to  complicate 


44  DISEASES   OF   WOMEN. 


pelvic  disorders.  It  is  often  extremely  difficult  to  differentiate 
between  the  two.  The  same  observation  applies  to  the  differentia- 
tion of  renal  and  hepatic  enlargements  or  tumours  of  these  viscera. 
The  frequent  occurrence  of  a  renal  calculus  giving  rise  to  various 
reflex  or  transferred  pains ;  the  possibility  of  a  renal  tumour  being 
mistaken  for  an  ovarian  cyst ;  the  different  morbid  conditions  for 
which  movable  kidney  is  liable  to  be  mistaken— such,  for  example, 
as  malignant  disease  of  the  colon,  tumours  of  the  gall-bladder,  fsecal 
tumours,  splenic  tumours — are  instances  of  this  (see  chapter  on 
'  Renal  Disorders '). 

Case  of  Congenital  Hepatoptosis — Liver  completely  displaced 
and  reaching  to  the  Right  Groin. 

In  a  case  of  mine,  the  supposed  enlarged  kidney,  the  edge  of  which 
could  be  felt  closely  simulating  the  margin  of  the  spleen  rather  than  that  of 
the  kidney,  proved  to  be  a  completely  displaced  liver  (hepatoptosis).  The 
patient,  who  had  some  time  before  been  almost  in  extremis  from  hsemate- 
mesis,  had  been  treated  for  gastritis  and  gastric  ulcer.  On  abdominal  explo- 
ration, I  found  the  liver  lying  completely  at  the  right  side,  the  gall  bladder 
displaced  from  its  position,  the  free  margin  of  the  liver  lying  forwards,  the 
organ  being  healthy,  but  congested,  and  reaching  to  the  right  inguinal  region. 
The  abdominal  viscera  having  all  been  carefully  examined,  and  the  liver 
replaced  in  its  position,  the  abdomen  was  closed,  with  the  curious  but  pleas- 
ing result  that  since  the  operation  the  patient  has  been  in  excellent  health.* 

Suppression  of  Urine  following  Shock — Hepatoptosis 
simulating  Hydro-nephrosis. 

Shortly  after  this  was  written  I  saw  a  case  of  suiDpression  of  urine  which 
lasted  for  eight  daj's.  A  large  bossy  swelhng  at  the  right  side  I  thought  was 
a  hydro-nephritic  accumulation.  The  suppression  had  followed  removal  of  a 
large  uterine  polypus  by  means  of  forceps.  No  urine  passing,  and  there 
being  no  cause  for  any  obstruction  in  the^  ureters,  I  was  puzzled  to  account 
for  the  hydro-nephrosis.  Everything  having  been  done  to  promote  the 
secretion  of  urine,  and  the  swelling  at  the  right  side  becoming  larger,  and 
aspiration  having  failed  to  draw  any  fluid  from  it,  I  advised  exploration,  and, 
on  opening  the  abdomen,  I  found  that  the  tumour  was  a  completely  displaced 
liver,  the  lower  border  of  which  reached  to  the  groin.  The  kidney  behind  it 
was  quite  healthy.     The  woman  died  from  the  suppression. 

But  it  is  especially  in  view  of  the  various  operative  procedures 

that  have  of  recent  years  been  undertaken  for  the  relief  of  renal 

affections,    both    in   the   kidney   itself   and   the    ureter,    that   the 

gynfecologist  must   remember  his    responsibility,  as    physician,   in 

*  Trans.  Med.  Soc,  vol.  xxi..  1898. 


Caecixoma  of  a  Large  [Mobile  Kidxet.     (ArxHOR.) 

The  hilum  and  the  renal  veins  are  invaded  with  new  growth ;  the  ureter  is 
healthy,  and  is  seen  cut  across.     Xephrectomy.     Eecovery.     (Page  45.) 

[To  face  J).  44. 


PLATE   IV. 


A 


The  same  Kidney  shown  in  Section.     (Author.) 

Tlie  ai-ea  of  healthy  structure  is  limited  by  a  line  drawn  from  A  to  B. 
Nephrectomv.     Eecovery.     (Page  45.) 

^ffZ' :/ v.^  /     ^-'^  '\r  ./  •  ^'  -   '' 


i;  '^:!^'  ;. 


.'^'^v- 


'  -.  1. 


Section  fkom  Carcinomatous  Area. 


[To  face  p.  4.5. 


AXATOMICAL  AND    CLINICAL.  -15 


diagnosing  the  disease,  and  advising  an  operation,  or  as  surgeon  in 
pei-forniing  it.  Only  those  who  are  frequently  called  upon  to  make 
a  diagnosis  can  lealize  the  difficulty  there  is  in  arriving  at  an 
accurate  conclusion  in  some  obscure  cases  of  renal  disease  if  they  be 
complicated  with  evidence  of  pelvic  mischief,  either  remote  or  imme- 
diate. The  vital  importance  of  extreme  care  is  obvious,  as  life  may 
be  sacrificed  from  the  want  of  a  simple  exploratory  incision,  or  the 
use  of  an  aspirator. 

Mobile  Kidney — Complicating  Uterine  Disease — Persistent  High 
Temperature — Supervention  of  Carcinoma — Nephrectomy. 

Tlie  plates  (11.  and  III.)  show  the  right  kidney  removed  by  nephrectomy  IVom 
a  lady  aged  40,  one  year  after  her  first  pregnancy.  There  had  been  a  brown 
discharge  from  the  uterus  for  a  year,  with  cessation  of  the  catamenia.  During 
the  entire  year  there  was  a  constant  nightly  exacerbation  of  temperature,  and 
uterine  disease  being  suspected,  slie  was  curetted.  At  the  same  time  she  had 
an  enlarged  and  movable  kidney.  Her  symptoms  not  being  relieved  by  curet- 
tage, exploration  of  the  kidney  was  suggested.  She  had  never  had  hsematuria, 
and  there  was  nothing  in  the  uterus  indicative  of  malignant  affection.  The 
uterus  and  adnexa  being  healthy  when  I  saw  her,  and  the  uterine  tumour 
having  increased  in  size,  I  suspected,  from  the  emaciation  and  sickness,  Avhicli 
were  increasing,  that  the  case  was  one  of  sarcoma.  The  kidney  was  removed 
by  Langenbuch's  operation.  She  made  an  excellent  recovery  and  put  on 
flesh.  Some  eighteen  months  after  the  operation  disease  recurred  in  the 
peri-renal  tissue,  and  she  died  within  two  years  from  the  primary  operation.* 

Summary  of  the  Pathological  Beport. — The  specimen  consists  of  an  enlarged 
right  kidney,  weighing  26|  ozs.,  and  measuring  7  inches  in  length,  and 
11  inches  in  its  greatest  circumference.  The  enlargement  is  due  to  the 
presence  of  a  new  growth,  which  involves  the  lower  two-thirds  of  the  organ. 
This  growth  has  a  nodular  surface,  and  is  closely  adherent  to  the  fibrous 
capsule  of  the  kidney,  though  it  has  not  perforated  the  capsule.  The  hilum 
shows  that  the  renal  veins  and  pelvis  are  plugged  with  new  growth.  The 
cut  surface  shows  that  the  renal  substance  is  entirely  replaced  by  growth  at 
the  lower  end  of  the  kidney.  Microscopically,  the  growth  is  a  verj^  soft  and 
degenerated  carcinoma. 

Microscopical  Eeport. — The  growth  itself  is  a  carcinoma  of  the  '  convoluted 
tube  '  type,  that  is  to  say,  it  reproduces  the  epithelium  and  general  arrange- 
ment of  the  convoluted  tubules  more  or  less  distinctly.  Some  of  the  alveoli 
have  a  lumen,  and  are  even  dilated  into  minute  cysts,  which  present  simple 
villous  ingrowths  or  papillomata.  The  majority  of  the  alveoli  are,  however, 
solid,  and  are  separated  by  thin  strands  of  fibrous  tissue  traversed  by  capillary 
vessels.  A  noteworthy  feature  of  the  gi'owth  is  the  marked  fatty  degenera- 
tion of  the  cells ;  this  is  shown  by  their  empty,  unstained  condition,  due  to  tlie 
removal  of  tlie  fat  in  the  course  of  preparation  of  the  specimen. 

*  For  particulars  of  case,  see  Brit.  Gijn.  Jour.,  Aug.,  1897. 


46 


DISEASES  OF   WOMEN. 


The  case  shows  the  care  with  which  the  differentiation  of  renal  tumours 
has  to  be  made.  It  demonstrates  the  importance  of  mobile  kidney  com- 
plicating disease  in  the  uterus  or  adnexa.  It  also  has  a  bearing  on  the 
influence  this  complication  may  exert  on  a  difficult  diagnosis  when  renal  and 
pelvic  disease  are  associated ;  and  it  is  of  great  interest  to  the  gyngecological 
surgeon,  both  from  its  cHnical  and  pathological  aspects. 

Ureters. — The  surgical  anatomy  of  the  ureters  has  of  recent 
years  come  to  have  a  special  importance  to  the  gynsecologist."'' 
This  has  resulted  from  the  surgical  measures  necessitated  by  the 
implication  of  the  ureters  in  affections  of  the  pelvic  viscera,  and 
the  various  operative  measures  which  have  been  taken  by  different 


Fig.  25. — Showing  Eelation  of  Uterus-  to  Uteeine  Arteries,  Ureters, 
AND  Bladder.    (Greig  Smith.) 

operators  to  avoid  injury  to  them,  or  to  repair  them  when  acci- 
dentally or  unavoidably  wounded.  Also,  the  examination  of  the 
bladder  by  cystoscopy,  and  the  catheterization  of  the  ureters  for 
diagnostic  purposes,  demand  a  correct  acquaintance  with  their 
position,  cystic  openings,  and  relations.  The  following  is  Collier's 
and  Morrison  Watson's  description  of  the  course  of  the  ureters  : — 

'  Entering  the  pelvis,  the  ureter  crosses  the  common  iliac  near  its  bifurcation, 
*  See  chapters  on  Myomata  and  Uretal  Surgery. 


ANATOMICAL   AXD   CLINICAL.  47 


and  theu  runs  downwards  and  forwards  in  front  of  the  internal  iliac  and 
its  anterior  division.  Where  this  division  of  the  internal  iliac  splits  into  its 
brandies,  the  m-oter  bends  backwards,  and  is  crossed  on  the  inside  by  the 
uterme  artery.  The  ureter  then  turns  forward  at  the  level  of  the  internal 
OS,  and,  at  a  distance  of  about  half  an  inch  from  it,  runs  along  the  side  of  the 
vagina  for  a  little  way,  finally  bending  over  it  so  as  to  enter  the  junction 
between  the  vagina  and  bladder.  It  perforates  the  latter  organ  just  above 
the  middle  of  the  anterior  vaginal  wall,  and  obliquely  enters  the  viscus  a  little 
lower  down.' 

Howard  Kelly,  to  whose  ingenious  method  of  exploration  of  the 
bladder  we  shall  refer  again,  has  added  to  the  knowledge  gained  by 
the  work  of  Griinfeld,  Newman,  Pawlik,  Sanger,  and  Schultze,  and 
I  quote  here  his  admirable  description  of  the  course  of  the  ureter  : — 

'  The  ureters  are  flattened  white  cords,  about  0"5  cm.  in  diameter,  from 
25  to  30  cm.  in  length,  extending  from  the  pelvis  of  each  kidney  high  up  in 
the  loins  under  the  vaulted  arch  of  the  thorax  down  to  their  embouchure  in 
the  urinary  bladder.  Each  ureter  is  naturally,  and  for  practical  purposes, 
divided  into  two  parts — an  abdominal  and  a  pelvic  portion — by  the  bend  over 
the  common  iliac  artery  at  a  plane  about  3  cm.  above  the  brim  of  the  superior 
strait. 

*  The  pelvic  portion  is  not  more  than  10  or  12  cm.  long,  while  the  abdominal 
portion  is  from  12  to  15,  or  more. 

'  The  most  inaccessible  portion  is  that  nearest  the  kidney,  where  it  lies  con- 
cealed by  the  ribs,  from  4  to  4-5  cm.  from  the  median  line,  and  about  the  same 
distance  posterior  to  the  anterior  face  of  the  vertebral  column. 

*  The  middle  part  of  the  abdominal  portion  lies  from  2*5  to  3  cm.  from  the 
median  line,  on  the  psoas  muscle,  on  a  plane  on  a  level  with  the  anterior  faces 
of  the  vertebral  bodies.  The  ureter  crosses  the  psoas  obliquely  to  the  internal 
iliac  artery  at  or  just  above  its  bifurcation,  where  it  is  about  3  cm.  from  the 
middle  of  the  promontory  of  the  sacrum.  The  course  is  thus  obliquely  down- 
ward and  inward,  exhibiting  a  slight  inward  convexity,  and  always  with 
marked  convexitj'  forward,  due  to  its  course  over  the  psoas. 

'  The  ureters  lie  in  the  loose  cellular  tissue  back  of  the  peritoneum,  and 
partly  under  the  caput  coli  and  the  ascending  colon  on  the  right,  and  descend- 
ing colon  and  sigmoid  flexure  on  the  left  side. 

'  The  abdominal  ureter  holds  no  relations  to  important  vessels  until  joined 
somewhere  about  or  above  the  middle  of  its  course  hj  the  ovarian  vessels, 
artery,  and  vein,  which  cross  it  to  descend  into  the  pelvis  along  its  outer 
border.  At  the  brim  of  the  pelvis  on  the  right  side  the  ureter  lies  just  behind 
the  peritoneum,  where  it  can  be  seen  with  the  ovarian  vessels.  The  perito- 
neum can  be  incised  at  this  point,  and  the  ureter  thus  easily  laid  bare. 

'  On  the  left  side  the  relations  of  the  ureter  to  the  sigmoid  flexure  and  the 
rectum  depend  entirely  upon  the  length  of  the  meso-sigmoid  and  the  variable 
position  over  the  superior  strait  at  which  the  rectum  enters  the  pelvis.  Thus 
in  one  case  the  ureter  lies  behind  the  sigmoid  veins  and  arteries^  and  in  another 
directly  behind  the  intestine. 


48 


DISEASES   OF    WOMEN. 


'  After  crossing  the  psoas  it  crosses  the  common  iliac  artery  obliquely  above 
its  bifurcation,  dropping  into  the  pelvis  at  this  point.  The  pelvic  portion  of 
the  ureter  usually  lies  at  first  to  the  inner  side  of  the  internal  iliac  artery  ; 
occasionally  it  lies  to  the  outside  ;  it  is  again  crossed  by  the  ovarian  vein  and 
artery,  which  leave  it  at  an  acute  angle  just  above  the  brim  of  the  pelvis  (the 
brim  was  made  by  the  muscle,  and  not  the  bony  pelvis).  The  pelvic  portion 
of  the  ureter  descends  to  the  floor  of  the  pelvis  in  the  loose  cellular  tissue  in 
a  forward  direction ;  it  passes  directly  under  the  uterine  artery  and  the  base 
of  the  broad  ligament,  alongside  the  upper  lateral  vaginal  wall,  and  finally 
curves  in  over  the  anterior  vaginal  wall,  following  its  uppermost  converging 
folds,  and  terminates  in  the  bladder,  where  the  two  urethral  orifices  are  con- 
nected by  the  inter-ureteric  ligament. 

'  The  ureter  can  be  palpated  through  the  anterior  vaginal  wall  from  its 
terminus  in  the  bladder  up  to  the  point  where  it  passes  beneath  the  broad 
ligament.  It  is  rolled  in  the  loose  cellular  tissue  under  the  index- finger,  or 
often  better  biniauually  under  two  fingers,  or  in  advanced  pi'egnancy  on  the 


'kMxhhym-'"''''^- 


Fig.  26. — Pelvic  Portiox  of  Ureter  from  below. 

/(.,  ureter;  o. c,  ovarian  vein ;  E,  rectum";  0,  ovary;  U,  uterus;  B,  bladder; 
u.ar..,  uterine  artery  ;  o.n.,  ovarian  nerve. 

head  of  the  child  like  a  narrow  tape  or  flattened  cord,  without  hardness.  It 
must  not  be  mistaken  in  this  position  for  the  obturator  artery  or  nerve,  or  the 
upper  border  of  the  levator  ani,  or  fibres  of  the  obturator  muscle,  or  the  rim 
of  the  foramen. 

'  A  diseased  ureter  becomes  nodular  and  thickened,  and  is  peculiarly  prone 
to  be  mistaken  for  a  cellulitis  or  an  adherent  ovary.  I  have  demonstrated 
this  fact  on  numerous  occasions  for  a  number  of  years. 

'  A  large  percentage  of  cases  under  treatment  to-day  for  cystitis  and  for 
irritable  bladder  are  in  reality  tender  thickened  ureters,  and  an  intelligent 
palpation  will  detect  the  tube  now  hard  and  cord-like,  bringing  out   the 


AXATOM/CAL   AND   CLINICAL. 


49 


L-liaracteristic  complaint  of  intense  desire  to  urinate.  One  patient  in  wIkhu 
I  persisted  in  maliing  the  examination  was  actually  forced  to  urinate  on  my 
hand. 

*  An  enlarged  ureter  can  easily  be  farther  pal[)ated  per  rectum  behind  the 
broad  ligament,  and  followed  from  there  up  over  the  posterior  pelvic  wall,  as 
I  was  also  able  to  demonstrate  on  a  case  in  the  hospital. 

'  I  have  found  that  the  normal  ureter  can  also  he  traced  and  minutely 
examined  in  the  wpi^er  jmrt  of  the  pelvic  course  hy  ivtroducing  a  ureteral 
catheter  through  the  urethra  and  bladder  into  the  ureter,  and  carrying  it  up 
to  or  over  the  brim  of  the  pelris.  When  an  inflexible  catheter  is  thus  carried 
over  the  brim,  the  ureter  is  displaced  upward  and  straightened  out.  It  can 
now  be  palpated  almost  as  plainly  through  the  rectum,  on  the  catheter,  and 


Fig.  27. — Diagkammatic  Figure  to  show  the  Portion  op  the  Ukktei; 
accessible  to  the  examining  flnger. 

«,  Base  of  round  ligament ;  b,  ureter  and  (cZ)  intra-ureteial  b"gament ; 
c,  trigone  ;  /,  urethra ;  g,  vagina. 

any  alterations  in  its  calibre  noted  almost  as  minutely  as  when  laid  bare  by 
dissection. 

'  At  the  pelvic  brim  the  ureter  can  also  be  felt  per  rectum. 

'  It  can  be  felt  at  the  brim  less  distinctly  through  the  anterior  al>dominal 
wall,  where  it  can  also  be  followed  for  G  or  8  cm.  up  toward  the  kidney,  while 
the  catheter  remains  in  place. 

'  My  landmark  for  the  upper  portion' of  the  pelvic  ureter  is  the  infer iial 
iliac  artery,  ivhich  can  readily  be  felt  per  rectum. 

'  In  some  cases  the  artery  can  be  palpated  up  to  the  common  iliac  artery. 
Close  along  the  inside  of  this  artery  the  ureter  can  be  felt ;  if  nothing  is  felt 
the  conclusion  that  this  portion  of  the  ureter  is  not  enlarged  is  safe. 

•xVmong  the  efforts  made  to  locate  the  abdominal  portion  of  the  ureters  by 
surface  landmarks,  I  know  none  which  have  thus  far  proven  satisfactory. 

]•; 


50 


DISEASES  OF   WOMEN. 


'  My  oiun  method  is  to  locate  the  promontory  of  the  sacrum  by  pressure 
through  the  abdominal  wall,  and  from  this  to  locate  the  point  at  which  the 
ureter  enters  the  pelvis  from  3  to  ^^  cm.,  outside  of,  and  a  little  below,  the 
promontory.  By  pressing  deeply  at  this  point,  the  fingers  at  once  recognize 
the  pulsations  of  the  common  iliac  artery,  a  sign  that  the  correct  spot  has 
been  found.  A  large  ureter  can  be  felt  at  this  point  through  thin  walls.  The 
patient  will  always  complain  of  severe  pain,  and  often  of  a  desire  to  urinate 
when  a  sensitive  or  inflamed  ureter  is  touched.' 

The  symptoms  due  to  a  stone  in.  the  kidney  in  a  young  girl  may 
be  attributed  to  spinal  disease,  or  to  some  uterine  or  ovarian 
affection.     Nor  does  it  infrequently  occvir  that  such  pelvic  disease 


Fig.  28. — Showing  the  Distukbed  Kelation  of  Paets  when  the  Uterus  is 

DRAWN    DOWN.      (GrEIG   SmITH — AFTER    SaVAGE.) 

K,  rectum;  U,  uterus;  B,  bladder;  P,  peritoneum  ;  T,  Fallopian  tube  ; 

O,  ovary. 

complicates  the  presence  of  a  renal  calculus.  The  various  opera- 
tions of  hysterectomy  demand  an  intimate  knowledge  of  the  rela- 
tion of  the  bladder  and  ureters  to  the  uterus  and  its  appendages. 
I  have  thought  it  desirable  thus  to  insist  on  the  advantage  it 
will  be  to  the  student  of  anatomy  to  take  every  opportunity  of 
studying  all  these  relationships,  and  noting  any  abnormalities  of 
these  viscera  or  in  their  vascular  supply. 


CHAPTER   II. 

FIRST    STEPS    OP   EXAMINATION    OF   A   CASE. 

As  in  the  ease  of  other  organs,  that  physician  is  most  likely  to 
arrive  at  a  sound  basis  for  his  treatment  of  the  uterus  who  makes 
his  first  examination  a  systematic  and  careful  one.  Many  an 
error  in  diagnosis  might  be  saved  if  we  adhered  to  this  rule.  One 
word  of  caution  is  needful.  "While  unnecessary  examinations  of 
the  uterus  are,  above  all  things,  to  be  deprecated,  on  the  other 
hand  nothing  can  be  more  dangerous  to  a  medical  man's  reputation 
than  the  neglect  of  making  a  careful  vaginal  examination,  when  he 
is  in  doubt  as  regards  the  nature  of  a  difficult  case,  with  symptoms 
clearly  pointing  to  some  affection  of  the  pelvic  viscera.  Want  of 
caution  in  this  respect  has  brought  many  a  young  medical  man  into 
disgrace.  Take,  for  example,  haemorrhage,  or  dysmenorrhosa,  the 
result  of  undetected  uterine  polypus ;  a  discharge  associated  with 
some  pelvic  suppurative  state  ;  irritability  of  the  bladder,  due  to 
a  displacement  of  the  womb,  a  pelvic  haematocele,  or  a  uterine 
fibroid ;  some  difficulty  in  deftecation,  attendant  on  a  tumour,  pelvic 
effusion,  or  uterine  displacement ;  frequency  in  making  water,  due 
to  undetected  stone  in  the  bladder  ;  a  prolonged  back-pain,  the 
result  of  retroversion  of  the  uterus.  The  most  serious  oversight  of 
all  is  the  non-discovery  of  malignant  disease.  This  I  have  known 
to  occur  on  several  occasions.  There  is  no  retreat  from  the  un- 
pleasant position  in  which  such  an  oversight  places  the  medical 
adviser.  These  are  just  a  few  instances  of  the  many  cases  in  which 
the  want  of  a  careful  vaginal  examination,  in  the  first  place,  is 
certain  to  reflect  discredit,  through  some  undiscovered  morbid  or 
abnormal  condition  of  bowel,  uterus,  or  bladder. 

The  appliances  necessary  to  make  a  first  examination,  in  the  great 
majority  of  cases,  are, — 

For  preliminary  examination  : — 


Bed  or  couch. 
Tape-measure. 


Stethoscope  or  phonendoscope. 
Specula. 


52  DISEASES   OF   WOMEX. 

Uterine  sound,  j   Clinical  thermometer. 

Catheter.  Absorbent  wool. 

Speculum  forceps.  I   Urinary  tests. 

(Oliver's  papers  and  Pavy's  pellets  are  convenient.) 


For  further  examination  : — 
Bartlett's  aspirating  needle. 
Laminaria      antiseptic 

sponge-tents. 
Uterine  dilators. 


Uterine  hook  or  tenaculum. 
A  general  ana-sthetic. 
Cocaine. 


The  final  appeal  must  be  made  to  the  microscope,  and  the  patho- 
logical and  bacteriological  iaboratoiy. 

History  of  the  Case. — We  first  take  the  history  of  the  case  some- 
what in  this  form  : — • 

Age ;  occupation  ;  married  or  single  ;  number  of  pregnancies  : 
number  of  abortions ;  date  of  last  pregnancy  or  miscarriage ;  if 
nursing ;  age  at  which  menstruation  began ;  dates  of  last  three 
periods ;  character,  quantity,  quality,  regularity  of  the  flow,  and 
if  associated  with  pain  ;  if  there  be  pain,  its  nature  and  seat ;  dis- 
charges, whether  inflammatory,  leucorrhceal,  sanguineous  ;  hereditaiy 
tendencies  in  the  family  history ;  state  of  the  bowel ;  sleep ;  appetite ; 
exercise  (power  of  walking).  It  may  be  well  to  make  a  few  brief 
observations  on  each  of  the  facts  thus  elicited  at  our  first  interview. 

Ag'e. — The  age  of  the  patient  has  an  important  bearing  on  the 
diagnosis  and  management.  Take,  for  example,  the  time  oi  puberty , 
with  the  physiological  influences  associated  with  the  commencement 
of  the  function  of  ovulation,  and  the  various  disturbances,  physical 
and  mental,  of  commencing  adolescence.  There  is  the  equally 
critical  period  of  life,  the  menopause,  when  the  active  discharge  of 
the  function  of  ovulation  is  ceasing,  and  the  child-bearing  epoch  is 
about  to  end. 

At  this  period,  also,  we  are  likely  to  meet  with  vicarious  ha?mor- 
rhage,  epistaxis,  ha?matemesis,  hfemoptysis,  retinal  haemorrhages, 
hgematuria. 

The  question  of  there  being  any  such  thing  as  cicarious  hxmorrliage  was 
raised  by  Wilks.*  For  my  part,  1  have  not  the  least  doubt  of  its  occurrence. 
I  have  had  several  cases  in  which  it  was  present,  as  a  consequence  of  sup- 
pression of  menstruation,  or  during  the  commencing  irregularity  of  the 
catamenia  at  the  menopause.  I  have  seen  it  in  the  form  of  epistaxis,  hfema- 
temesis,  and  haemoptysis. 

*  See  Kobei-t  Barnes's  paper,  Britisli  GyniBcological  Society,  April,  188G. 


FIRST  STEPS  OF  EXA2IINATI0N   OF  A    CASE.  5:J 

One  lady  I  attended  for  some  years,  and  whenever  the  catamenia  were 
suppressed  for  a  few  periods,  she  had  violent  hoemoptysis,  alarming  to  herself 
and  friends.  This  quite  ceased  with  the  end  of  the  climacteric,  and  she  re- 
inauied  in  perfect  healtli  for  years.  The  haemoptysis  generally  lasted  for  twu 
or  three  days,  and  was  always  checked  by  a  mixture  of  gallic  acid,  matico, 
ergot,  and  digitalis.  Before  the  hsemorrhage,  she  suflered  from  fulness  in  the 
head  and  shortness  of  hreath.  She  was  otherwise  a  robust  woman  and  in 
good  health.* 


Esthiomenic  Menstrual  Ulcer  of  the  Nose. 

A  young  lady,  aged  twenty-six,  was  attacked  with  a  small  ulcer  on  the 
inner  side  of  the  cartilage  of  the  nose.  This  resisted  various  forms  of  ti-eat- 
ment,  assuming  a  tubercular  or  lupoid  character.  At  each  menstrual  epoch 
redness  and  pain  supervened,  the  ulcer  becoming  very  irritable,  and  ulti- 
mately taking  the  form  of  a  malignant  ulcer,  with  a  hard,  dark-coloured  and 
depressed  slough,  with  raised  edges  and  inflamed  circumference,  threatening 
the  nose  with  destruction,  and  involving  the  lip  at  each  side.  The  agony 
the  patient  suffered  at  each  menstrual  period  was  great.  No  treatment 
arrested  the  extension  of  the  slough  save  complete  extirpation  with  the 
knife,  and  the  application  of  nitric  acid  or  chloride  of  zinc  paste  to  prevent 
its  recun-ence.  Seventeen  such  operations  had  to  be  performed  before  the 
nose  was  ultimately  cured.  Only  the  slightest  deformity,  however,  remains. 
The  portions  removed  were  several  times  subjected  to  bacteriological  ex- 
amination, but  nothing  definite  could  be  discovered.  The  ulceration  spread 
from  one  nostril  to  another,  at  one  time  reducing  the  skin  of  the  column  to 
the  thickness  of  about  two  lines,  and  extending  at  either  side  to  the  lip. 
There  was  no  doubt  of  the  esthiomenic  nature  of  the  ulcer  and  its  malignant 
tendency,  or  of  its  association  with  menstruation.f 

During  the  climacteric,  women  may  be  troubled  with  various 
head  troubles,  flushings,  pain,  migraine,  and  other  important  dis- 
turbances of  the  nervous  system,  as  convulsions  or  paralysis. 
Climacteric  insanity  manifests  itself  in  taciturnity,  melancholia, 
with  or  without  delusions,  and  hypochondriasis.  The  patient  has 
the  conviction  that  she  is  guilty  of  some  unpardonable  sin  against 
her  husband  or  family.  Suicidal  mimicry  may  be  present,  or  time 
suicidal  impulses.  Such  attacks  of  depression  or  exaltation  may  be 
alisent  or  greatly  lessened  in  the  intervals  between  the  menstrual 
periods,  and  at  these  epochs  the  fits  may  come  on  or  be  accentuated. 
All  such  cases  during  the  climacteric  require  exceptional  watcliing 
and  care.     They  are  typically  cases  for  nursing  and  supervision  in  a 

*  See  chapter  on  ^Menstrual  Disorders  for  remarks  on  Pigmentation  during 
Menstruation. 

t  A  full  report  of  this  unique  and  interesting  case  will  be  found  in  the 
Edinburgh  Journal  of  Medicfd  Science,  1898. 


54  DISEASES   OF  WOMEN. 

medical  home,  and,  save  in  rare  instances,  they  are  not  to  be 
treated  as  insane  women.  A  very  large  proportion  recover  when 
the  climacteric  has  passed.* 

There  is  the  intervening  j^eriod  of  active  ovulation,  during  which 
— the  child-bearing  period  —  the  woman  is  liable  to  any  of  the 
accidents  or  results  that  follow  from  deviations  from  the  normal 
physiological  act.  It  is  during  these  years  that  we  have  to  deal 
with  disorders  of  menstruation,  as  amenorrhcea,  dysmenorrhoea, 
monorrhagia,  leucorrhoeal  discharges ;  ovarian  troubles,  as  ova- 
ritis ;  ovarian  morbid  growths,  ovarian  solid  and  cystic  tumours  ; 
uterine  congestions,  inflammations,  growths,  alterations  in  position, 
flexions  and  versions,  and  all  the  results  of  these  abnormal  con- 
ditions. If  the  woman  be  married,  we  meet  with  those  affections 
which  are  often  directly  or  indirectly  connected  with  the  married 
state :  vulvar  and  vaginal  inflammation,  uterine  discharges,  specific 
sores  and  gonorrhoea,  perineal  laceration,  hfemorrhoids,  vesical  and 
urethral  complications,  ectopic  gestation,  pelvic  inflammation  and 
adnexal  tumours.  Both  in  the  single  and  married  woman,  malignant 
or  non-malignant  growths  are  more  apt  to  occur,  and  in  the  married 
the  various  disorders  consequent  on  lactation. 

Pregnancies  and  Abortions. — The  number  of  pregnancies  with 
their  successive  effects  on  the  constitution  of  the  woman  and  the 
uterus,  is  a  point  of  considerable  moment.  The  history  of  lacerations 
of  the  cervix,  subinvolution,  fistulse,  vesical  troubles,  or  mammary 
growths,  should  be  traced.  The  relation  of  fibroids  to  the  pregnant 
condition  may  be  ascertained.  Repeated  abortions  and  miscarriages 
lead  us  to  suspect  either  a  habit,  or  the  presence  of  syphilitic  taint, 
as  cause.  They  may  explain  some  accompanying  constitutional 
fault,  and  arouse  our  suspicion  of  latent  renal  mischief,  and  on 
examination  of  the  urine  we  detect  albuminuria  or  the  evidence  of 
granular  kidney.  Inquiry  into  the  possibility  of  a  specific  taint  is 
assisted  by  putting  cautious  questions  concerning  the  living  and 
dead  children,  the  dates  of  the  abortions,  and  the  various  periods  of 
pregnancy  at  which  they  took  place.  Most  important  of  all  con- 
tingencies for  the  practitioner  to  keep  in  view  is  that  of  ectopic 
gestation  and  its  consequences. 

Occupation  and   Habits. — This  inquiry  should  follow  that  into 

the  patient's  age :  whether  she  leads  an  active  or  sedentary  life ; 

if  she  has  to  stand  much,  or  to  do  a  great  deal  of  stooping  work ; 

if  she  sits  up  late  at  night,   dissipates,  or  spends  a  considerable 

*  See  chapters  on  uterine  reflexes-  and  sexual  correlations. 


FIRST  STEPS   OF  EXAMINATION  OF  A    CASE.  55 

time  at  the  piano,  painting,  or  the  sewing-machine ;  in  short,  how 
she  generally  occupies  and  amuses  herself.  This  inquiry  naturally 
touches  on  her  daily  habits — exercise,  clothing,  diet,  and  bathing. 
We  may  question  her  or  her  friends  as  to  the  outdoor  exercise  taken 
daily  ;  elicit  information  on  such  important  matters  as  tight  lacing, 
tight  garters,  the  manner  of  suspending  the  under-clothing,  the 
wearing  of  flannel,  and  if  the  temperature  of  the  extremities  be 
attended  to.  "We  learn  the  nature  of  her  food — if  healthful,  simple, 
and  nutritious,  or  trashy  and  indigestible  ;  the  times  of  meals,  and 
the  intervals  between  ;  the  quantity  of  alcohol  and  tea  consumed, 
the  hours  of  rest,  and  the  amount  of  sleep.  Not  the  least  important 
matter  to  elicit  is,  the  care  bestowed  on  the  skin.  The  resort  to  a 
daily  bath,  suited  in  its  degree  of  temperature  to  the  temperament 
of  the  individual,  is  perhaps  the  most  healthful  custom  a  woman 
can  adopt. 

Every  woman  should  have  a  sponge-bath  in  her  bedroom.  If  she  cannot 
take  the  cold  bath,  she  can  regulate  the  temperature  of  the  water,  according 
to  the  time  of  year,  from  60°  upwards,  and  have  proper  sponging  of  the  body, 
followed  by  friction  with  a  rough  towel.  Sea-bathmg,  again,  is  most  bracing 
and  suitable  for  many  constitutions.  It  is  quite  as  unfit  and  hurtful  to  others. 
It  is  well  to  find  out  exactly  how  the  sea-ah  and  sea-bathing  afiect  individuals 
before  we  either  permit  or  recommend  it. 

Sea  air  has  a  special  eflect  on  menstruation  in  some  women.  I  have  had 
several  cases  in  which  irregularity  occurred  as  a  consequence  of  change  to 
the  seaside  and  sea-bathing.  As  a  rule,  a  bracing  climate  and  mountam  air 
are  to  be  preferred  in  cases  of  en-atic  or  suppressed  catamenia. 

Menstruation."' — With  young  girls  we  frequently  find  a  difficulty 
in  coming  to  any  definite  conclusions  regarding  the  regularity,  the 
quantity,  and  the  quality  of  the  menstrual  flow — all  of  them  equally 
important  facts.  At  times  we  are  wilfully  deceived,  and  this  must 
always  be  remembered  in  cases  in  which  the  least  suspicion  of 
pregnancy  exists.  Here  we  must  place  little  reliance  on  assertions, 
and  ascertain,  if  possible  through  a  mother  or  relative,  if  the 
patient  has  menstruated  regularly.  Mothers  are  at  times  careless  in 
watching  the  occurrences  of  menstruation  ;  this  important  duty  is 
left  to  governesses,  schoolmistresses  and  servants.  Hence,  not 
seldom  does  it  happen  that  a  girl  is  brought  for  advice  for  some 
ansemic  or  chlorotic  state,  and  the  irregularity  of  menstruation 
associated   with    it    has  passed    unnoticed    and   unchecked.     It   is 

*  See  preceding  chapter  for  the  various  views  on  the  function  of  the  ovary 
and  the  relation  of  ovulation  to  menstruation. 


56  DISEASES   OF   WOMEX. 

necessary,  in  such  instances,  that  we  should  insist  on  a  careful 
watch  being  kept  on  the  periods  and  the  character  of  the  discharge. 
If  there  be  suffering  with  the  period,  we  must  learn  the  time  when 
the  pain  is  most  severe  ;  if  it  precede  the  flow,  and  disappear  or 
continue  dui'ing  its  occurrence  ;  if  there  be  nervous  disturbances, 
headaches,  symptoms  of  cerebral  congestion  or  hysterical  tendencies. 
Tinnitus  aurium  or  visual  aberrations  may  guide  us  to  an  ophthal- 
moscopic examination,  and  the  discovery  of  arterial  tension,  optic 
neuritis,  hypersemia  of  the  retina,  or  an  error  of  refraction.  Ab- 
normal retinal  states  will  suggest  a  urinary  examination,  and  possibly 
the  detection  of  some  latent  renal  disorder.  It  will  be  important  to 
date  accurately  the  commencement  of  any  irregularities,  whether  in 
diminution  or  excess  ;  also,  if  there  be  menorrhagia,  to  know 
whether  any  slight  discharge  continues  in  the  intervals  between  the 
periods,  and  its  quantity.  If  the  patient  has  been  regular  and  has 
ceased  to  be  so,  we  look  for  some  cause  for  the  first  irregularity,  as 
indiscretion  in  exercise,  in  dress,  in  bathing  ;  perhaps  in  mental  shock 
or  emotion,  or  in  climate,  or  in  the  period  of  life. 

Discharges. — I  shall  have  occasion  more  fully  to  refer  to  the 
diagnostic  importance  of  uterine  and  vaginal  discharges  in  another 
chapter.  I  may  here  briefly  allude  to  the  character  of  the  dis- 
charge, which  has  to  be  ascertained  at  the  first  examination.  It 
may  be  in  nature  mucoid,  purulent,  muco-purulent,  sebaceous, 
sanguineous ;  it  is  described  as  creamy,  flaky,  thick  and  viscid, 
gelatinous,  transparent,  or  acid  ;  in  colour,  grayish,  white,  yellow, 
or  brown ;  at  times  it  is  tinged  with  blood,  or  it  may  be  of  an 
olive-colour ;  it  may  have  a  very  heavy  odour  or  be  extremely  fcetid. 
All  these  qualities  indicate,  more  or  less,  the  soiirce  and  nature 
of  the  discharge.  Our  opinion  is  fortified  or  verified  by  a  micro- 
scopic examination,  when  the  presence  of  pus  and  the  kind  of 
epithelium,  whether  squamous  or  columnar,  can  be  determined. 

Appliances  necessary  for  Diag-nosis. — It  is  necessary  to  refer 
to  the  objects  gained  by  the  use  of  the  appliances  already  alluded 
to  as  required  in  a  careful  diagnosis. 

Bed  or  Couch. — In  order  to  make  a  correct  diagnosis  we  have 
to  proceed  as  follows :  The  patient  is  either  in  bed  or  on  a  couch. 
For  use  in  private  I  prefer  the  latter. 

A  good  examining  couch  should  be  constructed  so  as  to  raise  readily  the 
hips  of  the  patient.  The  complicated  and  ingenious  mechanisms  which  are 
advertised  are  quite  unnecessary.  All  we  reqiiii'e  is  a  couch  or  table  of  con- 
venient height  and  breadth,  one,  over  the  end  of  which  the  buttocks  can  be 


FJJ!sr  stj::ps  of  kxamixatiox  or  a  case.  57 

convenieutly  drawn,  and  the  thighs  supported  in  rests  that  are  attached  to  it. 
In  a  private  consiiltint^  room  the  less  obtrusive  or  conspicuous  a  couch  is  tlic 


Fig.  'I'd. — Patilxt  in  Sims'  Semi-prone  Position  on  Couch. 

better.  For  jjiivate  practice  a  light  couch  (Figs.  29  and  30)  can  be  constnicted, 
with  a  drawer  at  the  end  for  appliances.  It  should  be  conveniently  high  for 
tlie  woman  to  get  on  to  without  anj'  difficulty,  and  for  the  operator  to  sit  at 
the  side  or  end  of  to  conduct  any  necessary  manipulations.  A  light  rug  or 
wrap  should  be  at  hand  to  cover  the  extremities,  and  the  majority  of  examina- 
tions can  be  conducted  with  little,  if  any,  exposure  of  the  patient.  The 
couch  should  have  an  incline  from  the  foot  to  the  shoulders  of  5  inches,  and 
the  top  can  be  sloped  upwards  to  nearly  the  same  level  as  the  foot.  It  is  a 
good  plan  to  have  a  light  stand 
for  appliances,  made  the  same 
height  as  the  couch,  opposite 
the  operator's  chair,  and  an- 
other chau"  at  the  left-hand 
side  at  its  head,  on  which  a 
friend  can  sit.  She  can  thus  be 
cheered  and  encouraged,  while 
her  delicacj"  is  not  hurt. 

It  is  wonderful  how  a 
little  gentleness  and  con- 
sideration, with  a  due  re- 
gard to  a  woman's  feelings, 
especially  in  unmarried 
girls,  will  enable  us  to  con- 
duct an  examination  which 
any  roughness  or  rudeness 
would  make  impossible.  We 
can  place  a  woman  on  her 
left  side,  on  hei-  back,  or  in 
the  semi-prone  position  of 
IMarion  Sims.  It  is  im- 
possible to  get  the   last-named  posture  properly   in  any  ordinary 


Fig.  30. 


-End  of  Couch,  with  the  Leg- 
rests  ADJUSTED. 


58 


DISEASES   OF   WOMEN. 


bed,  yet  it  is  undoubtedly  indispensable  in  several  manipulations 
of    the    uterus.       For   the   majority    of    first    examinations,    it    is 


Fig.  31. — Leg  Support. 

The  thigh-rests  are  attached  to  the  strap  by 
buckles — one  end  of  the  strap  being  brought 
under  the  left  axilla. 


Fig.  32. — CErTCH  or  Vox  Ott 
(St.  PetePiSbueg). 

The  long  strap  fixes  the  patient 
to  the  couch  or  table. 


sufficient  to  place  the  woman  on  her  left  side,  her  thighs  drawn 

up  to  the  abdomen  (if 
in  bed,  the  body  should 
be  placed  diagonally), 
with  the  buttocks 
brought  to  the  edge 
and  the  left  arm  carried 
behind  the  back,  the 
face  resting  on  the 
pillow.  It  is  best  to 
examine  on  a  hard  mat- 
tress, and,  if  required, 
a  few  pillows  may  be 
placed  under  the  hips 
to  raise  them.  The 
couch  or  table  must  be 
opposite  a  good  light. 
After  a  first  examina- 
tion, and  when  further  exploration-  of  the  uterus  and   adnexa   is 


Fig.  33. — Portable  Table  foe  Trexdelenbueg's 
Position. 


FIRST  STEPS   OF  EXAMINATION  OF  A    CASE. 


59 


necessary,  or  the  duckbill  speculum  is  employed,  the  dorsal  position 
and  bimanual  method  is  by  far  the  best.  The  bimanual  examination 
is  absolutely  necessary  in  every  thorough  exploration  of  the  uterus 


FlO.   34. — BUIANUAL   EXAHINATIOX,   FKOM   HOWAED   KeLLY,    SHOWIKG   THK 

DiPFEBENT  Positions  of  the  Hands  and  Fingers. 

and  pelvic  viscera  when  a  complete  diagnosis  of  a  tumour,  whether 
of  the  uterus  or  adnexa,  has  to  be  made.  By  its  means  alone  can 
we  satisfactorily  determine  the  size,  mobility,  and  relation  of  the 
uterus.     By  this  method  we  have  more  complete  command  over  the 


Fig.  35. — Excellent  Opekating  Tab4.e,  Nickel  axd  Glass,  suitable  fok 
ALL  Abdominal  Operations.* 

adnexa,  and  can  best  judge  of  alterations  in  their  size,  of  adhesions, 

of  the  character  of  the  enlargements  both  of  the  uterus  and  adnexa. 

It  is  the  examination  to  make  when  the  patient  is  under  an  ansesthetic. 

*  I  usually  operate  upon  this  table,  and  can  recommend  it.    (Messrs.  Arnold.) 


60 


DISEASES   OF   WOMEX. 


-Table  in  the  Teendelekbueg 
Position. 


When  we  determine  to  adopt  the  semi-prone  position  wfe  do  so  thus :  Any 
square  table  about  4  feet  by  2  feet  6  inches,  having  a  blanket  smoothly 

spread  on  it,  answers  the  pur- 
pose admirably.  The  patient 
lying  down  on  this  surface,  on 
her  left  side,  with  the  bodj' 
placed  diagonally,  the  buttocks 
well  to  the  side,  has  the  thighs 
drawn  up  ;  the  left  arm  is  next 
taken,  and  the  back  of  the  left 
hand  is  laid  on  her  left  scapula. 
The  right  hand  is  now  allowed 
to  hang  over  the  side  of  the 
couch,  while  the  face  is,  when 
possible,  partly  turned  towards 
the  operator.  Thus  the  ster- 
num and  chest  are  brought  well 
on  to  the  plane  surface.  At 
times  we  may  not  be  able  to 
accomplish  this,  but  we  thus 
secure  the  most  favourable  de- 
pression of  the  sternum.  An 
assistant  or  nurse  to  hold  the  speculum  steady  and  in  position — a  little  art  in 

itself — is  required.* 

Attendant  in  Study. 
—  So  many  serious 
charges  have  of  late 
been  made  against  me- 
dical men,  that  I  deem 
it  right  to  emphasize 
the  caution  given  in  the 
text,  so  that  the  prac- 
titioner may  put  it  out 
ct  the  power  of  any 
designing  or  hysterical 
woman  to  bring  a  charge 
of  criminal  assault 
against  him  by  taking 
such  precautions  as  will 
make  this  impossible. 
Also,  in  those  equally 
serious  cases  in  which 
women,  more  often 
those  of  the  better 
classes,  come  for  the  purpose  ot  securing  abortion,  the  medical  man  cannot 
be  too  cautious.  Women  are  most  importunate  and  pertinacious  in  their 
*  For  ordinary  use  in  an  examination  under  an  ansestlietic  Howard  Kell}''s 
les'-rest  is  most  convenient. 


Fig,  37. — Table  adjusted  fok  Vaginal 
Operations. 


FIRST  STEPS   OF  EXAMIXATIOX  OF  A    CASE. 


61 


endeavours  to  effect  this  purpose.  A  medical  man  may  be  made  the  victim 
of  a  plot  to  throw  the  blame  off  the  slioulders  of  another.  A  woman  may 
wilfully  deceive  him  as  to  the  occurrence  of  the  catamenia  or  of  lisemorrhage, 
and  the  impossibiHty  of  conception.  A  false  charge  of  effecting  criminal 
abortion  may  be  the  consequence,  and  if  the  practitioner  be  not  waiy  and 
determined,  appearances  and  circumstances  may  be  urged  against  him  that  he 
could  never  have  anticipated.  Circumspection  and  caution  to  a  degree  that 
niay  seem  almost  unnecessary  are  demanded  in  order  to  defeat  either  hysterical 
delusion  or  deliberate  intrigue.  The  obligations  of  professional  honour  and 
fair  play  impose  on  all  practitioners  the  need  for  the  greatest  care  and  re- 
ticence in  listening  to  any  such  stories,  when  whispered  of  a  brother  pro- 
fessional. It  is  doubtful  if  so  many  such  unfortunate  cases  would  occur 
save  for  the  too 
ready  ear  of  some 
medical  man,  who, 
either  designedly  or 
through  incaution, 
has  countenanced  a 
groundless  suspicion, 
or  favoured  a  charge 
absolutely  ruinous  to 
the  character  of  him 
against  whom  it  is 
made.  Such  precau- 
tions are  all  the  more 
necessary  in  these 
days,  when  women 
generally  are  so  con- 
versant with  medical 
matters,  and  read  the 
details  of  these  cases 
in  the  daily  press,  or 
gather  their  informa- 
tion from  medical 
literature,  to  which 
they  have  too  free 
access.  In  every  case 
in  which  the  prac- 
titioner has  the  least  suspicion  as  to  the  object  of  a  womaii's  visit,  or  whi-n 
she  makes  any  illegal  request,  he  should  take  a  note  in  luriting  of  her  name, 
residence,  time  of  coming  to  and  leavyng  his  room,  the  data  on  lohich  he 
formed  the  opinion  he  gave,  the  advice  that  accompanied  this  opinion,  and  of 
any  prescr>x>tion  he  may  have  written. 

The  Tape-measure  is  useful  foi-  abdonainal  measurements.  We 
may  require  to  take  the  circumference  at  the  umbilicus,  and  the 
lateral  measurements  from  it  to  the  spinal  column,  and  from  the 
umbilicus  to  the  anterior  superior  iliac  spine  to  the  symphysis.    We 


Fig.  38. — Patient  ox  the  Table  of  Doyex  ix  ihi: 
Complete  Teexdelexbukg's  Positio::. 


62 


DISEASES   OF   WOMEN. 


thus  estimate  the  amount  of  abdominal  distension,  and  the  size  of 
a  tumour,  or  the  relative  difference  and  degree  of  inequality  between 
either  side.  The  value  of  careful  measurements  is  exemplified  by 
the  following  case. 


Anomalous  Tumour  of  Ovary  causing  Lameness, and  Symptoms 
of  Hip-joint  Affection. 

The  plate  (IV.)  shows  a  solid  ovarian  tumour  of  an  anomalous  nature  re- 
moved at  the  same  time  as  a  large  fibro-myoma.  The  patient  was  sent  for 
examination  in  consequence  of  an  obscure  affection  of  the  left  hip ;  there  had 
been  constant  pain  and  swelling  of  the  left  thigh,  with  difficulty  in  walking. 


^   "^^Ste. 


Fig.  39.— Microscopical  Appearances  of  Anomalous  Ovarian  Tumour. 
( Vide  Plates  IV.  and  V.)  ^ 

The  catamenia  had  been  regular.  There  was  no  haemorrhage.  I  determined 
that  her  symptoms  were  due  to  the  pressure  from  the  tumour.  Intraperitoneal 
hysterectomy  was  performed. 


PLATE   V. 


FiBRO-ADEXOMA   OP    THE    OVAliY    OCCURRING   WITH    A    FlBKOMYOMATOUS   UtEETjS. 

(Author.) 
Abdominal  Salj^iiigo-Oophorectomj'. 


To   SHOW    LOBILATED    EXTERNAL    SURFACE    OF   THE    TuMOUR. 

[To  face  p.  (J2. 


PLATE   YI. 


FiBROMTOlIATOUS   IjTEEtlS   EEMOTED   FEOM   THE   SAME   PaTIEXT   FROM   "WHOM 

THE  OvAKT  (Plate  Y.)  was  takex.     Recovery.    (Author.) 

ITofacep.  63. 


FIBST  STEPS  OF  EXAMINATION  OF  A    CASE.  63 

The  multiple  fibromatous  ovarian  mass  was  then  discovered  on  the  left 
side.  It  was  larger  than  an  orange.  This  was  jammed  downwards  and  to 
the  left  side.  The  patient  made  a  perfect  recovery.  The  microscopical 
report  of  the  committee  of  the  Obstetrical  Society  was  as  follows :  '  The 
tumour  (part  involved  in  the  growth)  consists  chiefly  of  well-developed  fibrous 
tissue  arranged  in  intersecting  bundles — sections  taken  from  ditferent  parts 
show,  in  addition,  numerous  widely  distributed  well-defined  spaces  fitted  with 
epithelial  cells.  These  spaces  are  irregularly  oval  or  elongated,  occasionally 
branching,  and  there  is  no  lumen.  There  is  no  sign  of  invasion  of  the  sur- 
rounding fibrous  tissue  by  the  epithelial  cells,  and  no  small-celled  infiltration. 
The  stroma  suri'ounding  some  of  the  spaces  is  dense  and  hyaline  in  appear- 
ance.' The  decision  arrived  at  was  that  the  tumour  was  not  malignant,  and 
that  in  the  arrangement  of  the  epithelium  it  most  nearly  resembled  that  met 
with  in  some  forms  of  adeno-fibroma  of  the  breast. 

The  Stethoscope  is  required  for  the  difierential  diagnosis  of 
pregnancy  from  ovarian  dropsy,  ascites,  fibrocyst  and  fibroid 
tumours  of  the  uterus,  phantom  pregnancy,  and  other  causes  of 
abdominal  enlargement.  It  is  also  required  for  pulsating  tumours 
of  the  abdomen,  and  in  the  diagnosis  of  these  from  aneurismal 
enlargement  of  the  vessels.  The  phonendosco^e  is  of  special  value 
in  abdominal  auscultation. 

The  Tubular  Speculum  is  employed  to  see  the  uterine  cervix  or 
the  vaginal  walls ;  in  pathological  states,  as  in  erosion,  lacerations, 
congestion,  polypus,  malignant  growths  and  ulceration,  and  when 
a  good  view  of  the  uterine  cervix  is  necessary  ;  also  in  inflam- 
matory states  of  the  vagina,  or  to  detect  fistula  and  growths.  In 
virgins  its  employment  is  to  be  avoided  whenever  possible.  Never 
should  it  be  taken  in  the  hand  for  introduction,  in  such  cases, 
unless  its  assistance  be  indispensable  for  diagnosis  or  treatment. 

The  impression  made  on  a  patient  by  our  first  examination  may 
secure  her  future  confidence.  Gentleness  of  manipulation  must 
be  cultivated,  and  especially  in  the  use  of  any  speculum.  It  is  best 
to  begin  with  a  smaller-sized  conical  one.  I  prefer  that  with  the 
rounded  and  bevelled  end,  as  it  does  not  hurt  in  the  same  way  as 
those  with  a  sharper  edge. 

Vulcanite  specula  are  easily  disinfeeted,  and  cannot  be  broken.  The  dis- 
advantage of  these  specula  is  that  the  edges  are  rather  sharp,  and  hurt  in 
introduction;  also,  they  do  not  reflect  the  light  well.  The  short  bivalve 
speculum  of  Barnes  is  a  useful  instrument.  It  completely  exposes  the  intra- 
vaginal  cervix.  Fergusson's  glass  speculum  (Fig.  47),  of  which  we  require 
three  or  four  sizes,  is  generally  made  too  long.  The  uterine  end  should  not 
be  sloped  at  too  great  an  angle.     It  throws  a  good  light  on  the  os  uteri, 


6i 


DISEASES    OF    WOMEN. 


and  is  useful  for  topical  applications.     It  can  be  had  of  toughened  glass, 
fenestrated  speculum  is  not,  as  a  rule,  of  any  special  service. 


A 


Fig.  40. — Metal  Vtjlcanite-covered  Duck-bill  Speculum.    (Leitek.) 


Fig.  41. — Vulcanite  coated  Speculum  axd  Dressing  Forceps. 
(Leitek.) 

Most  useful  in  vaginal  operations  in  which  antiseptics  are  emploj-ed,  and  in 
post-operative  dressings. 


■Fig.  42. — Tapering  Speculum  of  Author  with  the  Bevelled  Emp  su 
cushioned  internally  as  to  prevent  the  Concealment  of  any  S£C!KEtiox. 

Made  of  light  metal,  highly  polished.  It  can  be  had  in  three  sizes.  It  must 
not  taper  too  much.  (I  have  a  full-sized  non-tapering  speculum  of  this 
kind,  made  for  use  in  multipara.) 


FIRST  STEPS   OF  EXAMINATION  OF  A    CASE. 


(if) 


The  duck-bill  speculum  (Figs.  40  and  45),  or  Neugebauer's  (Fig. 
46)  variety  of  it,  is  used  in  the  semi-prone  or  dorsal  positions.  It 
is  indispensable  to  the  gynjiecologist  in  manipulations  on  the  os  uteri 
and  cervix.  In  fact,  in  all  cases  in  which  it  is  possible  to  employ 
the  duck-bill  speculum  it  is  better  to  do  so. 

Specula  must  be  kept  scrupulously  clean,  not  alone  for  the  sake  of  better 
illumination,  but  also  to  avoid  the  risk  of  any  contagion  in  the  examination 
of  several  cases  with  the  same  mstrument.  Metal  duck-bill  specula  are  made 
by  Leiter  (Vienna)  coated  with  vulcanite ;  these  can  be  thrown  into  mercuric 
chloride  solution  without  detriment.  It  is  well  to  place  all  specula  in  some 
disinfectant  fluid  after  they  have  been  used,  and  before  they  are  finally 
washed  with  very  hot  water. 

To  apply  a  tubular  speculum  :  place  the  patient  on  her  back,  or 
on  her  left  side,  in  the  position  before  described.  The  speculum  is 
first  well  anointed  with  a  disinfectant  cream.  If  the  lateral  position 
be  chosen,  the  right  buttock  is  raised  with  the  palm  of  the  left 
hand,  and  the  fingers  of  the  same  hand  are  used  to  separate  the 


Fig.  43.— Sims'  Hook. 

labia.  The  speculum,  with  the  long  lip  posteriorly,  is  now  pressed 
gently,  but  steadily,  through  the  vulvar  orifice.  It  is  now  pushed 
onwards,  in  a  direction  upwards  and  backwards,  hearing  well  on  the 
perineum,  until  we  reach  the  posterior  cul-de-sac  of  the  vagina,  and 
get  the  cervix  well  into  the  instrument.     At  times  this  is  not  easy ; 


Fig.  44.— Single  Texaculum  Forceps 


the  uterus  may  be  considerably  anteverted  or  retroverted.  A  little 
practice  and  experience  will  enable  us,  with  the  uterine  sound,  to 
direct  the  os  uteri  forwards  or  backwards  so  as  to  bring  it  into 
sight.  By  rotating  the  speculum,  withdrawing  it  a  little  and  re- 
introducing it,  we  can  generally  obtain  a  complete  view  of  the 
circumference  of  the  cervix  and  the  os  uteri.     The  line  of  meeting 

F 


66 


DISEASES   OF   WOMEN. 


of  the  vaginal  walls  seen  through  the  instrument  should  be  kept  in 
the  centre  of  the  surface  exposed  to  view.  If  we  place  the  woman 
on  her  back,  we  insert  the  speculum,  and  press  it  well  back  on  the 
perineum    in  passing  it  into  the  vagina.      In  this  manner  the  os 


Fig.  45. — Sms'  Duck-bill  Speculum. 
The  blades  of  the  speculum  should  not  be  too  deeply  grooved,  nor  too  long ; 
those  ordinarily  made  frequently  are.     Every  practitioner  should  have  two 
sizes  of  the  duck-bill  speculum. 

uteri  generally  comes  into  view  readily,  and  the  patient  can  herself 
often  give  valuable  assistance  in  supporting  the  speculum,  if  we 
happen  not  to  have  an  assistant.     The  speculum  forceps  (Fig.  50)  is 


Fig.  46. — Neugebauer's  Speculum.* 


Fig.  47. — Fergusson's 
Speculum. 


required  with  the  speculum,  and  some  pledgets  of  absorbent  cotton- 
wool ready  at  hand,  to  wipe  the  surface  of  the  os  uteri,  and  to  clear 
the  vaginal  roof  of  any  discharge  that  may  have  accumulated  or  be 

*  See  chapter  on  Operations  on  the  Vagina  for  the  Various  Ketractors. 


FIJiST  STEPS   OF  EJAJIIXATTOX   OF  A    CASE.  67 

pressed  out  by  the  speculum.  It  is  well  to  have  a  few  uterine 
cotton-holders  if  we  require  to  wipe  out  from  the  interior  of  the 
cervix  any  discharge  with  cotton-wool.  To  use  the  duck-bill 
speculum  in  the  semi-prone  position  of  Marion  Sims,  an  assistant 
stands  at  the  back  of  the  patient  and  places  the  left  hand  flat  on 
the  right  gluteal  fold,  holding  it  well  up  ;  the  ))lade  of  the  speculum 


Fig.  iS. — Author's  Tcbulak  Speculum  Slice. 
Useful  in  irrigation  of  the  vagina. 

is  now  introduced  in  rather  an  oblique  manner  to  the  orifice,  the 
labia  being  gently  separated  ;  and  while  it  is  pushed  upwards  and 
backwards  it  is  rotated  on  its  axis,  and  the  back  of  the  speculum  is 
brought  against  the  perineum.  It  is  then  carried  into  position, 
directed  by  the  finger.     It  will  be  found  that  more  room  is  obtained. 


Fig.  49. — Bath  Speculum. 

and  the  uterus  is  better  seen  and  more  readily  controlled,  in  the 
dorsal  position.  Once  the  speculum  is  properly  adjusted,  and  the 
cervix  uteri  is  brought  well  in  front  of  the  blade,  the  finger  of  the 
right  hand,  or  the  handle  of  the  sound,  must  be  carried  up  to 
the  anterior  vaginal  wall,  which  is  thus  held  out  of  the  way.     The 

Speculum  with  Electric  lUumination.  — Various  specula  fitted  with  the  electric 
light  have  been  devised.  Furst  has  devised  a  self-retaining  speculum,  to  which 
a  self-retaining  electric  light  is  attached.  They  can  be  obtained  of  any  medical 
electrician.     Ttsere  is  a  good  deal  of  the  electric  toy  in  these  specula. 


DISEASES   OF   WOMEN. 


uterus  is  generally,  by  this  method,  well  exposed  to  ^iew.     If  we 

require  to  bring  it  down  for  medication,  or  to  steady  it  for  topical 

application,  we  use  a  Sims'  uterine  hook,  or,  what  I  prefer,  a  slender 

double  tenaculum  forceps.     It  is  fixed   in  the 

anterior  lip  of  the  uterus,  and  the  os  uteri  is 

thus  drawn  into  view. 

Neugebauer's  speculum  (Fig.  46),  a  modification  of 
Sims',  has  in  some  instances  the  advantage,  through  its 
double  blade,  that  it  enables  the  operator  to  draw  up 
the  anterior  vagiual  wall.  When  applied  it  acts  like  a 
bivalve  speculum,  and  is  to  an  extent  self-retaiaing. 
The  posterior  blade  having  been  adjusted,  the  anterior 
is  slipped  within  it,  and  is  so  guided  into  position. 
The  vaginal  roof  is  thus  stretched,  and  a  good  view 
of  the  uterus  is  obtained.  There  are  other  modifica- 
tions of  Neugebauer's  speculum  which  it  is  not  neces- 
sary to  refer  to. 

Demonstrating  Vaginal  Speculum. — The  desirability 
of  having  such  a  portable  speculum  as  would  enable 
the  surgeon  to  demonstrate  to  a  student,  at  the  bedside, 
the  OS  uteri  and  infra-vaginal  cervix,  without  exposm'e 
of  the  patient,  often  struck  me  in  hospital  work.  By 
such  an  appliance  as  that  shown  in  Fig.  51,  this  can 
be  perfectly  achieved.  It  consists  of  a  nickel-plated 
steel  bracket  with  three  joints,  as  shown  in  the  figure, 
which  are  so  constructed  as  to  enable  the  mirror  to 
be  placed  at  any  angle  or  plane  to  the  orifice  of  the 
speculum,  from  which  it  is  25  centimetres  distant. 
A  clamped  ring  with  a  groove  receives  the  mouth  of 
the  speculum,  and  will  fit  one  of  large  size.  This 
may  be  so  arranged  that  any  ring  can  be  apphed  so 
as  to  embrace  a  smaller  speculum.  At  the  other  end 
of  the  bracket  is  a  miiTor,  which  works  in  a  universal 
joint.  It  is  3  inches  in  diameter.  If  it  be  wished  to 
get  a  magnified  image,  a  shghtly  concave  muTor  can 
be  attached. 

The  OS  uteri  can  be  seen  at  a  distance  either  by 
sunlight  or  artificial  hght,  without  exposure  of  the 
patient. 

The  Uterine  Sound  (Figs.  53-55)  takes  the  place  of  a  long 
obstetric  finger.  The  more  the  practitioner's  experience  is  enlarged 
by  careful  digital  examinations  of  the  vagina,  uterus,  and  the 
adnexa,  the  less  he  will  feel  the  need  for  the  sound.  Most  con- 
ditions can  be  accurately  and  satisfactorily  ascertained  without  it. 
The  himanual  method,  aided,  if  need  he,  hy  the  recto-vaginal,  carried 


FJBST  STEPS   OF  EXAMINATION  OF  A    CASE. 


69 


out  in  both  the  dorsal  and  semi-prone  positions,  seldom  leaves 
Its  in  tJonht  as  to  the  size,  and  mobility,  and  hardness  of  the  uterus, 
the  state  of  the  adnexa,  and  condition  of 
ihe  cervix  and  os.     A  good  uterine  sound 


Fig.  51. — Deuoxstkatiox  Specclxjm  of 
ArTHOR. 


Fig.  52. — AppuAycE  folded 
(J  size). 


should  be  pliable  and  smooth,  and  if  graduated  it  is  better  to  have 
the  scale  on  the  concave  side.  It  can  be  made  portable  for  the 
pocket,   either    by  a   screw  joint    in  the  centre,  or  the 


Fig.  53. — Slmpsos's  Soxtnt). 


upper  half  of  the  instrument  may  screw  into  a  case  which  acts  as 
a  handle.  It  should  not  be  too  heavy.  The  sound  is  used 
both  for  diagnostic  and  therapeutical  purposes ;  in  diagnosis, 


Fig.  5i. — Si3is'  Pliable  Probe. 
to   ascertain   the   length   of   the   uterine   cavity  and   the   patency 


Fig.  55. — Acthor's  Small  Portable  Solxd,  ■«^TH  Central  Screw. 
of  the  canal,   the  mobility   of  the  uterus  and  its   position  in  the 


70 


DISEASES   OF    WOMEN. 


pelvis ;  it  is  used  in  utero-rectal  and  recto-vesical  examinations,  as 
in  the  diagnosis  of  hsematocele,  polypus,  and  inversion  of  the  uterus. 


Fig.  56.— Author's  Combixatiox  of  Elevator  a>'d  Sound 
(Messrs.  Arnold.) 

The  cupped  ivory  end  screws  on  to  tlie  silver  shank.  The  handle  is  of  alu- 
minium. It  is  grooved  and  notched  so  that  it  can  be  covered  with  chamois 
or  a  layer  of  cotton  wool  if  used  through  the  rectum  in  the  retroversion  of 
pregnancy.     It  makes  an  admirable  and  well-balanced  sound. 

The  principal  therapeutical  purpose  of  the  sound  is  in  versions 
and  flexions,  to  take  the  place  of  a  repositor.     To  introduce  it  into 

the  uterus,  we  proceed  thus  : — 
The  patient  is  placed  in  the 
lateral  or  semi-prone  position. 
The  thighs  are  well  drawn  up, 
while   the   nates  are   brought 
over   the    edge    of   the  couch. 
The  instrument  is  taken  lightly 
by  the  handle  in  the  left  hand, 
while  the   point   of   the   fore- 
finger   of    the    right   hand    is 
carried    up   to    the   os    uteri, 
which  is  felt,  and  its  direction 
and  the  position  of  the  uterus 
fairly  ascertained.     The  sound 
is  now  introduced  into  the  va- 
gina, with   the    concavity    to- 
wards the  perineum   and  the 
handle  directed  backwards  ;  it 
is  next  guided  along  the  index- 
finger  of  the  right  hand  to  the 
OS  uteri.    As  a  rule,  with  some 
little    manipulation   it    enters 
the  cavity  of  the  cervix ;  it  is 
then  carried  along  the  cervical 
canal,  and  now  the  handle  is 
turned  in  the  operator's  hand, 
de  mattre  is  brought   round  with  a  gentle  sweep, 


Fig.  57. — First  Stage  of  passing  the 
Sound.    (Hart  and  Bakbour.) 


and   by  a  tour 


FIRST  STEPS  OF  EXAMINATION  OF  A    CASE. 


71 


uutil  it  is  directed  towards  the  perineum,  so  as  to  have  the 
concavity  now  facing  anteriorly,  and  thus  the  instrument  is 
directed  into  the  uterine  axis  in  its  normal  and  slightly  anteverted 
position.  It  is  now  carried  onwards,  passing  over  the  forefinger  of 
the  right  hand,  still  held  in  position,  until  it  reaches  the  fundus 
uteri.  This  we  judge  it  to  have  done  by  the  slight  sense  of 
resistance  we  feel  to  the  onward  passage.  "We  should  not  make  the 
woman's  sense  of  pain  a  test.  In  certain  softened  states  of  the 
uterine  tissues  it  would  be  possible  to  penetrate  the  uterine  wall 
and  still  cause  very  little  pain. 

The  usual  difficulties  experienced  in  passing  the  sound  are  caused  by  con- 
traction, or  stenosis  of  the  canal  of  the  isthmus  uteri,  or  flexions,  or  versions. 
There  may  be  such  a  degree  of 
narrowing  that  it  is  impossible  to 
pass  the  instrument,  or  we  may 
only  succeed  with  the  pliable  silver 
uterine  probe  of  Sims.  In  vereions 
we  must  carry  the  handle  well 
back  to  the  perineum,  or  forwards 
to  the  pubes,  according  as  we 
have  an  anteversion  or  a  retro- 
version to  deal  with ;  if  there  be 
also  a  flexion,  we  may  have  to 
bend  the  sound,  and  endeavour, 
by  giving  it  the  necessary  curve, 
to  glide  it  over  the  bend.  We 
pass  the  sound  into  the  bladder  in 
recto-vesical  and  urethro-vaginal 
methods  of  examination.  We 
must  always  remember  the  sine 
qua  non  of  obstetric  practice — that 
before  taking  the  uterine  sound 
into  our  hand  for  any  therapeutical 
or  diagnostic  purposes,  we  exclude 
the  possibility  of  pregnancy*  Also, 
it  is  well,  after  all  tedious  examina- 
tions with  it,  if  these  be  made  at 
the  operator's  house,  to  take  everj' 
precaution  against  cold ;  and  the 
simplest  plan  to  prevent  this  is  to  place  a  dry  plug  of  absorl^ent  wool  in 
the  vagina,  to  be  withdra\\Ti  by  the  patient  herself  after  a  few  hom-s.  In 
this,  as  in  a  number  of  other  trifling  uterine  operations,  the  immunity  from 
all  harm  that  may  have  followed  us  for  years  may  be  suddenly  and  unplea- 
santly interrupted  when  we  least  expect  it — the  attack  of  uteiine  colic  or  of 
endometritis,  or  perimetritis,  is  suddenly  developed,  and  alarming  symptoms 

*  See  remarks  on  the  differential  diagnosis  of  pregnancy. 


Fig.  58. — Second  Stage  of  passing 
SoTran.     (Habt  and  Bakboue.) 


72 


DISEASES   OF   WOMEN. 


may  occur  that  a  little  prudent  forethought  would  have  prevented.  Take, 
for  example,  the  neglect  of  the  safe  maxim,  to  refrain  from  the  use  of  the 
sound  immediatety  before  a  menstrual  peiiod  is  approaching. 

By  keeping  the  forefinger  of  the  right  hand  at  the  os  uteri,  and 
placing  its  tip  on  the  concave  surface  of  the  sound  when  it  has 

penetrated  to  its  full  extent, 
■we  can  estimate,  by  the  gra- 
duated grooves,  the  exact 
length  of  the  uterine  canal. 
Before  removing  it  we  can 
test  the  mobility  of  the  uterus, 
raise  it,  or  replace  it  in  posi- 
tion ;  and  also  Judge  com- 
paratively, by  utero-rectal, 
utero-abdominal,  and  utero- 
vaginal examination,  of  any 
abnormal  connection  of  the 
uterus  with  some  neighbour 
ing  viscus,  or  attachments 
that  have  formed  between  it 
and  other  morbid  pelvic  and 
abdominal  formations  and 
growths. 

In  introducing  the  sound  it 
may  be  caught  and  arrested  by 
some  fold  of  mucous  membrane, 
or  the  knob  (which  should  always 
be  of  fair  size)  may  enter  a  small 
By  partly  withdrawing,  and  gently  passing  it  on  again, 


FrCr.  59. — Sound  ix  Utero;  Kecto- 

TTERIXE    EXASHNATION. 


follicular  cul-de-sac. 


Fifi.  CO.— Pkopek  Method  of  Eotation  of  the  Sound,  as  cojipaeed  with 
THE  Impkoper.    (Hart  and  Barbour.) 


FIRST  STEPS  OF  EXAMINATION  OF  A    CASE. 


73 


we  get  over  tlie  obstruction.     Again,  at  the  isthmus  we  may  find  its  passage 

impeded.     One  golden  rule  must  be  observed — never  use  force.     Better  to 

withch-aw  the   knob   of  the   sound 

from  the  uterus,  and  with  the  finger 

in  the  vagina  give  the  point  of  it  a 

new  curve,  bending  it  a  little  more 

forwards  or  backwards,  or  laterally, 

and   again   try  to  slip  it  into   the 

cavity  of  the  fundus.     Frequently, 

in  extreme  cases  of  anteflexion  or 

retroflexion,   we    shall    succeed    in 

passing  it  by  thus  repeatedly  altering 

its  shape  and  changing  the  direction 

of  the  handle,  until  we  hit  off  that 

which  enables  it  to  pass  through  the 

altered  curve  of  the  uterine  canal. 

In  extreme  retroversion  we  may 
have  to  carry  the  handle  forwards 
to  the  pubes,  and  chrect  the  con- 
cavity backwards  ;  *  we  next  feel 
for  the  OS  uteri,  and  pass  the  sound 
onwards,  giving  the  handle  such 
elevation  or  dip  as  will  assist  the 
knob  to  pass  on  into  the  cavity. 
When  the  elbow  of  the  sound  is 
reached,  by  a  semicircular  sweep, 
we  revolve  the  sound  on  its  axis 
and  thus  alter  its  direction,  while  at  the  same  time,  by  lowering  the  handle, 
we  raise  the  uterus  from  its  depressed  position  (Fig.  61). 

The  Urine. — An  examination  of  the  urine  is  often  required,  and, 
indeed,  few^  cases  of  any  complicated  local  affection  can  be  viewed 
satisfactorily,  either  from  a  diagnostic  or  prognostic  aspect,  unless 
a  urinary  examination  be  made. 

In  Oliver's  test-papers  we  have  very  delicate  tests  for  albumen ; 
and  the  ex;amination  may  be  carried  out  at  the  bedside,  all  we 
require  being  a  small  test-tube,  I  have  found  the  potassio-mercuric- 
iodide  the  most  dehcate  of  these  papers,  detecting  albumen  where 
heat  and  nitric  acid  have  failed.  The  indigo-carmine  papers  are 
equally  reliable  for  sugar. 

This  table  of  comparative  analyses  of  male  and  female  urine  by  Becquerel 
may  be  useful  as  a  guide  in  judging  of  abnormal  urine  : — 


Fig.  61. — Eecto-vesical 

EXAinXATIOX. 


See  chapter  on  'Ke trover sion.' 


74 


DISEASES   OF   WOMEN. 


Comparative  Analyses  of  Male  and  Female  Ueine  (Becquerel).* 


Mean  Com- 

Mean Com- 

position of 

position  of 

General 

Four  Healthy 

Four  Healthy 

Mean. 

Men. 

Women. 

Specific  gravity    .... 

1018-9 

1015-12 

1017 

Percentage  of  water 

96-88 

97-.50 

97-19 

„          „    solids     . 

3-11 

2-49 

2-80 

„          „    urea 

1-38 

1-03 

1-21 

„           „     uric  acid 

0-039 

0-040 

0-039 

„          „    other  organic  matter 

0-92 

0-80 

0-86 

„          „     chlorine   (combined, 

fixed) . 

— 

— 

0-05 

„          „    phosphoric  acid 

— 

— 

0-03 

„          „    potash    . 

— 

— 

0-13 

„          ,,     soda,  lime,  and  mag- 

nesia . 

— 

.  0-39 

We  proceed  in  practice  thus — 

Take  a  specimen  of  the  urine.     Find  its  specific  gravity  at  60°,  reaction 
with  litmus,  and  the  quantity  passed  in  the  24  hours. 
Albumen — sp.  gr.  1006  to  1010.     Test  by  Oliver's  potassio-mercuric-iodide 

papers  (I  find  it  necessary,  in  order  to  avoid  error,  always  to  apply  heat 

after  a  precipitate  is  obtained  with  Oliver's  paper) ;  heat  180°,  and  nitric 

acid  a  few  drops — precipitate ;  Pavy's  citric  acid  and  ferro-cyanide  pellet. 

Heller's  test — small  quantity  of  urine  and  cold  nitric  acid  allowed  to  run 

down  the  side  of  the  test-tube. 
Phosphates — sp,   gr.   increased  slightly:    heat    180°,    precipitate   obtained, 

which  nitric  acid  dissolves ;  phosphatic  crystals  under  microscope. 
Urates  and  uric  acid — sp.  gr.  1025  to  1030 ;  heat  dissolves ;  hexagonal  or 

rhomboidal  crystals  of  urea,  with  nitric  acid ;  also  uric  acid  crystals 

under  microscope. 
Sugar — sp.  gr.   1030  to  1050.     Johnson's  picric  acid  test ;  indigo-carmine 

test  of  Oliver ;  Trommer's  and  Fehling's  Tests ;  Pavy's  pellets  afford  a 

ready,  convenient,  and  reliable  test  for  sugar  (directions  accompany). 
Pus — Coagulates  with  heat ;  deposit  forms  homogeneous  layer  at  bottom  of 

glass ;  becomes  gelatinous  with  liqiior  potasses ;  mixes  with  the  urine ; 

pus  corpuscles  under  microscope. 
Mucus — Deposit  often  glairy,  tenacious ;    urine  generally  alkaline  ;    is  not 

miscible  with  urine  ;  rendered  less  dense  by  liquor  potasses ;  acetic  acid 
•    gives  a  sort  of  membrane  floating  in  the  urine. 
Blood — Discoloration  with  heat ;  formation  of  coagidum;  blood  corpuscles 

under  microscope.     Almen's  test — freshly  prepared  tincture  of  guaiacum 

and  ozonized  ether — ^blue  colour. 


'  Urinary  Analyses.' 


FIMST  STEFS   OF  EXAMINATION   OF  A    CASE. 


75 


Proportion  of  Urinary  Constituents  in  Normal  Urine.* 


FOR   ADULT    MAN.  FOB    ADULT   WOMAN. 


Total  quantity  of  urea  iu  24  hours.   [  H5  grammes 
Percentage  of  urea       .         .         .      2-35  % 
Total  quantity  of  uric  acid   .         .1  gramme 
Percentage  of  uric  acid  f       ■         •   '  U'UGG  % 

Katio  of  uric  acid  to  urea.  1  :  35. 


Total  quantity  of  chlorine     . 
Percentage  of  chlorine  % 
Expressed  as  sodium  chloride 
Total  quantity  of  phosphoric  acid . 
Percentage  of  phosphoric  acid 


7'5  grammes 

0-5  % 

3'6  grammes  per  oz. 
3'16  grammes 
0-21  % 


80  grammes. 

2-3  %. 

0857  grammes. 

0-066  7o- 

6"75  grammes. 
0-52  %. 

3'8  grammes  per  oz. 
2-8  grammes. 
0-22  %. 


Clinical  Thermometer. — It  may  seem  superfluous  to  refer  to  the 
value  of  an  accurate  record  of  temperature  in  arriving  at  a  diagnosis, 
and  conducting  the  management  of  a  case.  The  importance  of  such  a 
record  is  made  more  obvious  if  we  reflect  for  a  moment  on  the  causes 
of  nightly  exacerbations  of  temperature,  or  a  daily  elevation  of  a  few 
degrees  above  the  normal  standard.  In  peritonitis,  pelvic  hsematocele, 
metritis,  suppurating  cysts,  acute  vaginitis  ;  in  chronic  peritonitis ; 
in  ursemic  and  septicaemic  states,  and  cystitis,  we  may  expect  the  cha- 
racteristic rise  and  fall  in  the  temperature  range.  In  pelvic  eflfusion, 
especially  if  pus  be  forming,  the  nightly  exacerbation  is  the  rule ; 
in  ectopic  gestation  also  the  temperature  record  is  valuable. 

With  the  previous  history  of  a  case,  an  accurately  kept  chart  of 
the  temperature  will  materially  assist  a  physician  in  forming  a 
correct  diagnosis. 

An  Anaesthetic  is  absolutely  necessary  to  enable  us  to  arrive  at  a 
correct  diagnosis  in  certain  cases  of  uterine  and  adnexal  tumours, 
in  the  differentiation  of  pelvic  from  abdominal  tumours  when  we 
require  complete  relaxation  of  the  abdominal  wall ;  also  when  there 
is  a  suspicion  of  phantom  pregnancy,  and  when  there  is  great 
sensitiveness  of  the  parts,  rendering  an  examination  without  it 
extremely  diflicult,  if  not  impossible. 

As  to  the  choice  of  an  anaesthetic  in  operative  gynaecology,  this 
must  always  to  a  certain  extent  depend  upon  the  individual  case 
under  consideration.  I  was  one  of  the  first  in  the  United  Kingdom 
to  strongly  advocate  the  employment  of  ether  in  general  surgery, 

*  This  is  the  standard  proportion  on  which  the  Clinical  Research  Association 
analyses  are  estimated.     I  am  indebted  to  the  Director  for  this  table, 
t  Somewhat  high — corresponds  with  recent  and  more  accurate  analyses. 
t  According  to  Parkes — rather  high. 


76  DISEASES   OF   WOMEX. 

and  for  many  years  most  of  my  operations,  abdominal  and  other, 
were  done  under  nitrous  oxide  gas  and  ether,*  Previous  to  this  I 
had  myself  administered  methylene  and  chloroform  some  fifteen  to 
sixteen  hundred  times  without  an  accident,  and  I  have  never  had 
a  fatal  result  with  gas  and  ether.  Oxygen  was  first  given  for 
me  by  Dudley  Buxton  both  as  a  prophylactic  and  restorative. 
Only  on  the  rarest  occasions  have  there  been  respiratory  or  heart 
complications.  For  the  last  few  years  I  have  used  chloroform  in 
all  my  abdominal  cases,  believing  that  some  serious  gastro-intestinal 
symptoms  were  induced  by  ether,  such  as  persistent  vomiting,  foul 
tongue  and  breath,  fcetor  of  the  evacuations,  distressing  cough,  and 
bronchial  complications.  I  am  convinced  that  these  post-operative 
consequences  are  less  frequently  met  with  after  chloroform.  On 
the  other  hand,  I  feel  that  occasionally  chloroform  with  ether  is 
the  preferable  anaesthetic,  and  that  there  are  abdominal  cases  in 
which  the  administration  of  chloroform,  touching  both  the  safety  of  the 
patient  and  the  comfort  of  the  operator,  should  devolve  on  specially 
skilled  hands.  Now  that  we  know  the  limits  within  which  anaesthesia 
may  be  secured  and  maintained  in  the  case  of  chloroform  (half  to  2 
per  cent,  of  air)  and  that  we  have  in  the  inhaler  of  Vernon  Harcourt 
an  apparatus  which  registers  accurately  the  percentage  of  chloroform 
inhaled,  we  are  on  much  more  certain  ground  than  in  the  past. 

In  previous  editions  I  entered  fully  into  the  question  of  ansesthesia, 
and  the  different  metliods  of  administration.  This,  however,  is  now 
unnecessary,  inasmuch  as  every  student  and  practitioner  has  the 
opportunity  of  making  himself  proficient  in  these.  It  is  of  un- 
speakable advantage  to  a  surgeon  when  his  operation  is  conducted 
under  the  skilled  and  experienced  hand  of  a  thoroughly  reliable 
anaesthetist.  In  the  accidents  and  emergencies  of  abdominal  sur- 
gery, in  the  necessity  for  prolonged  administration  in  the  face  of 
collapse  from  shock  and  haemorrhage,  the  skill  and  resources  of  the 
anaesthetist  are  put  to  the  test  to  save  the  operator  from  distraction, 
and  to  enable  him  with  confidence  to  proceed. 

In  our  natural  desire  to  record  our  most  striking  surgical  successes,  we  are 
too  often  led  by  a  rather  selfish  egoism  to  forget  altogether,  or  at  least  to 
minimize,  the  extent  to  which  we  are  indebted  for  our  results  to  the  skilful 
administration  of  an  anfesthetic.  A  prolonged  operation  is  frequently  one  in 
which  there  is  considerable  loss  of  blood,  and  as  a  consequence  associated 
shock ;  yet  it  is  often  under  these  very  conditions  that  we  require  the  full 

*  '  Medical  Responsibility  in  the  Choice  of  Ansesthetics,  with  the  Ansesthetics 
employed  and  the  Mode  of  Administration  in  Fifty  Large  Hospitals  in  the 
United  Kingdom.'    Lewis,  London,  1876. 


FIRST  STEPS  OF  EXAMINATION  OF  A    CASE. 


77 


anjesthetic  effect,  and  wliile  we  demand  absolute  immobility  of  the  patient, 
we  trust  entirely  to  the  skill  of  the  administrator,  and  trouble  ourselves  only 
with  immediate  regard  to  our  own  manipula- 
tions. In  our  anxiety  for  exactitude  and 
celerity,  we  take  no  count  of  the  judgment  that 
determines  the  approach  of  shock,  that  is  ever 
on  the  alert  for  the  accidents  of  anaesthesia, 
and  that  forestalls  these  without  any  unneces- 
sary fuss  or  distraction  of  our  attention. 
Changes  in  the  position  of  the  patient,  re- 
sterilization  of  infected  parts,  as  well  as  the 
hands  of  the  operator  and  his  assistants,  are 
under  anaesthesia  easilj'  efifected.  If  we  can  . 
thus  complete  the  thorough  sterilization  of  the 
abdomen  and  vagina,  immediately  before  ope- 
rating, without  distressing  the  patient,  so  can 
we  finish  the  abdominal  toilet,  and  carry  out 
all  its  aseptic  details,  before  she  recovers  con- 
sciousness. Also,  as  the  success  of  an  opera- 
tion must  depend  in  great  measure  upon  our 
pre-knowledge  of  its  nature  and  the  probable 
steps  that  the  peculiarities  of  the  case  will  de- 
mand, our  decision  must  be  based  upon  an 
accurate  diagnosis,  which  latter  can  only  be 
arrived  at  in  many  instances  by  the  assistance 
of  an  anaesthetic* 


I  have  operated  in  several  cases  requiring 


Fig.  61a. — Mr.  Vebnon  Har- 
court's  Chloroform  Eegu- 

LATOK. 


prolonged  anaesthesia  in  which  the  chlorO-    a.  Two-necked  bottle  filled  as  far  as 
.     .  ,  ^  _^  top  of  conical  part  with  chloro- 

torm  was  administered  by  Vernon  Har-  - 

court's  inhaler,  and  with  perfect  satisfac- 
tion. For  the  greater  part  of  the  operation 
the  percentage  of  chloroform  administered 
did  not  exceed  from  half  to  one  per  cent. 
Dudley  Buxton,  who  gave  the  anaes- 
thetic in  these  cases,  writes  as  follows  : — 


form ;  b,  inspiratory  valve,  through 
which  air  enters  alter  passing  over 
surface  of  the  chloroform  in  a  ;  c, 
stop-cock  and  pointer,  the  former 
regulating,  the  latter  indicating, 
the  percentage  of  chloroform  in- 
haled ;  d,  inspiratory  valve ;  e, 
joint  for  keeping  apparatus  ver- 
tical, an  essential  in  order  that  the 
valves  shall  work  true;  /,  ex- 
piration valve. 


•  By  means  of  this  apparatus  the  vapom-  of  chloroform  is  mixed  with 
air ;  all  dilutions  from  zero  to  2-5  of  chloroform  can  be  obtained.  When 
the  patient  is  fully  narcotized  and  the  pupils  contracted,  which  occurs 
usually  when  a  2  per  cent,  vapour  is  given,  but  sometimes,  especially  in 
the  case  of  children,  when  only  1  per  cent,  or  1-5  per  cent,  is  reached,  the 
operation  is  commenced.  The  time  of  induction  varies,  but  five  to  ten 
minutes  is  the  average  duration.  Usually  the  strength  of  1  per  cent,  or 
even  less  is  competent  to  maintain  a  complete  narcosis.     I  have  used  this 

*  Ethyl  chloride  has  been  given  for  the  author  by  Mr.  T.  Bakewell  in  several 
cases,  but  always  in  coDJunctiun  with  gas  and  ether. 


78  DISEASES   OF   WOMEN. 

apparatus  now  for  a  large  number  of  the  most  severe  ojierations,  including 
bad  brain  cases,  cholecystectomies,  enterectomies,  stomach  operations,  short- 
circuitings,  ablation  of  plunging  goitres,  with  severe  dyspnoea,  abdominal 
sections  for  hysterectomy,  and  pelvic  operations,  some  of  which  have  lasted 
a  long  time  and  have  never  failed  to  obtain  a  most  satisfactory  anaesthesia, 
placid  as  sleep  and  apparently  without  in  any  cases  causing  narcotization  of 
the  medullary  centres.  The  amount  of  excitement  is  usually  very  slight,  and 
after-effects  are  certainly  less  than  when  higher  percentages  are  employed. 
The  patients  appear  to  have  little  discomfort,  and  from  personal  trial  it  may 
be  shown  that  low  percentages  are  tolerated  and  hardly  noticed  as  the  narcosis 
is  in  progress.  If  a  higher  percentage  than  2  per  cent,  is  needed — which 
I  am  inclined  at  present  to  doubt — it  can  always  be  obtained. 

'  Speaking  from  my  own  experience,  I  can  only  affirm  that  I  am  convinced 
that  Vernon  Harcourt's  regulator  is  immeasurably  superior  to  any  other 
apparatus  at  present  in  use.  A  little  intelligence  and  study  render  it  easy  to 
master  its  technique.  In  praising  this  apparatus,  I  must  add  that  it  is  only  an 
apparatus,  and  although  it  minimizes  dangers,  it  does  not,  of  course,  obviate 
the  necessity  that  the  person  using  it  shall  know  the  principles  of  chloroform, 
ansesthetization,  or  the  necessity  that  he  shall  possess  that  sense  of  responsi- 
bility which  alone  can  qualify  to  undertake  the  conduct  of  an  anaesthesia.' 

Some  Rules  to  be  observed  in  the  administration  of  any  Anaesthetic. 

1.  When  possible,  the  operator  should  not  be  the  ansssthetist. 

2.  The  latter  should  not  be  conversed  with  during  the  administration. 

3.  The  anaesthetist  should  not  leave. 

4.  The  heart  and  lungs  of  the  patient  should  be  examined  before  adminis- 
tration. 

5.  The  stomach  should  be  comparatively  empty. 

6.  The  temperature  of  the  room  should  be  at  least  60°.  The  body  ought 
to  be  free,  and  all  tight  clothing  should  be  loosened. 

7.  Any  artificial  teeth  should  be  removed. 

8.  The  breathing  and  countenance  should  be  carefully  watched  all  through 
the  administration,  which  should  immediately  cease  on  the  warning  of  danger 
in  failure  of  the  pulse  and  signs  either  of  cerebral  ansemia  in  the  face  or  of 
asphyxia.  By  pulling  the  lower  maxilla  upwards  and  forwards,  placing  the 
thumbs  behind  the  ramus  at  either  side,"the  patient's  jaw  is  raised,  and  with 
it  the  hyoid  bone.  The  tongue  may  be  pulled  forward  with  a  tongue  forceps, 
the  body  inverted  by  Nekton's  method,  and  galvanism  applied  along  the 
course  of  the  pneumo-gastric  or  over  the  heart,  while  strychnine  or  sulphuric 
ether  is  injected  subcutaneously.  Artificial  serum  may  be  used  if  there  be 
shock  from  haemorrhage.  In  cases  in  which  prolonged  anaesthesia  is 
anticipated,  and  the  circulation  feeble,  the  subcutaneous  use  of  strychnine 
before  operation  is  advisable. 

Howard,  of  New  York,  advocated  the  complete  extension  of  the  head  and 
neck  as  the  best  means  of  raising  the  epiglottis  and  hyoid  bone.  He  main- 
tains that  this  plan  is  much  more  efficient  than  elevation  of  the  jaw ;  also,  he 
contends  that  traction  of  the  tongue  does  not  raise  the  epiglottis.  Bringing 
the  head  over  the  edge  of  the  table  or  bed,  so  that  it  may  swing  quite  free, 
he  carries  it  firmly  backwards  and  downwards,  by  placing  one  hand  under 


I 


FIRST  STEPS   OF  EXAMINATION  OF  A   CASE. 


tlie  chin  and  the  otlier  ou  tlio  vertex.     The  utmost  possible  extension  of  the 
head  and  neck  is  thus  maintained.     The  skin  is  to  be  made  quite  tense. 

9.  While  the  patient  is  passing  under  the  influence  of  the  anajsthetic 
or  coming  therefrom, 
silence  should  he  kept 
and  no  observations 
bearing  on  her  case 
or  the  operation  be 
made. 

I  have  spoken  of 
the  examination  of 
the  heart  before  the 
administration  of  an 
anesthetic.  Of  course, 
it  is  well  known  that 
the  most  experienced 
anaesthetists  daily 
administer  ether, 
chloroform,  and 
uitroiis  oxide,  witliout 
taking  this  precau- 
tion. I  do  not  think 
that  is  an  example  to 
be  followed  by  the 
ordinary  practitioner, 
or  by  any  one  whose 
opinion  may  not  have  sufficient  weight  with  an  ignorant  jury.  If  the  anaes- 
thetist be  a  specialist,  and  considers  such  an  examination  a  matter  of  form  or 
superfluous,  in  the  event  of  a  fatal  issue  he  can  better  set  himself  right  before 
a  coroner's  court  than  one  who  is  not  in  the  position  of  an  expert. 

Cocaine. — Local  ansesthesia  of  the  external  genitals  and  vagina 
may  be  effected  by  the  use  of  cocaine,  either  in  the  form  of  oint- 
ment (10'20  per  cent.)  or  solution.  The  ointment  may  be  freely 
smeared  over  the  part  or  applied  on  a  piece  of  cotton-wool.  In  the 
•case  of  a  sensitive  vulvar  orifice,  cocaine  may  be  used  for  the 
purpose  of  examination,  but  this  is  rarely  necessary.  It  is  useful 
in  some  minor  operations  on  the  vulva,  and  may  be  applied  for  any 
painful  operation  to  the  external  surface  of  the  cervix.  A  variety 
of  minor  operations  may  be  performed  on  the  outlet  with  the  electro 
cautery  painlessly  under  cocaine.  Lanolated  lard  is  the  best  basis 
if  we  use  it  as  an  ointment  (lanoline  3ss.,  lard  5iv.,  rosewater  5i-)' 

Spinal  Analgesia. — The  production  of  analgesia  by  sub-arachnoid  injections 
of  cocaine,  on  account  of  the  attendant  sickness,  the  subsequent  headache, 
and  the  probable  difficulty  of  operating  in  the  face  of  unexpected  complica- 
tions, is  not  likely  to  be  of  much  use  in  intraperitoneal  operations.  Tufter, 
who  has  operated  over  250  times  under  cocaine  analgesia,  is  of  this  opinion. 


Fig.  62. — Chlorofokm  and  Ethee  Ixhaler. 
(ScHAEDEL,  Leipzig.) 
A,  nickel  case,  with  two  bottles — larger  for  ether,  the 
smaller  for  chloroform.  E,  F,  tube  communicating 
with  the  bottles.  By  taps  the  bellows  can  be  turned 
on  to  either  or  both  of  the  bottles.  By  these  taps 
the  relative  amount  of  the  anaesthetics  can  be  regu- 
lated. This  is  an  admirable  inhaler  for  the  adminis- 
tration of  either  chloroform  or  ether,  or  both. 


80 


DISEASES   OF    WOMEN. 


A  needle  is  entered  one  centimetre  to  the  right  of  the  fourth  lumbar  spinous 
process,  and  when  the  sub-arachnoid  fluid  escapes  the  cocaine  is  injected. 
The  patient  is  sitting  with  the  trunk  bent  slightly  forwards.* 

Tents  are  employed  for  exploration  of  the  uterine  canal,  as  in 
cases  where  we  suspect  polypus  of  the  uterus,  retention  of  portion 
of  the  membranes  after  abortion,  and  in  monorrhagia,  when  we  are 
uncertain  of  the  cause  of  the  discharge.  Their  employment  in 
certain  operative  procedui'es  I  shall  have  occasion  to  refer  to. 

Tents  used  in  this  country  are  of  thi'ee  kinds — sponge,  sea-tangle 
or  laminaria,  and  tupelo-root  (Nyssa  multijiora).     There  are  certain 

dangers  that  may  fol- 
low from  any  kind  of 
tent :  uterine  colic,  col- 
lapse, metritis,  perito- 
nitis, parametritis,  te- 
tanus, septicaemia.  I 
have  twice  seen  an 
alarming  condition  su- 
pervene   within    three 


Fig.  63.— Tupelo  Tent. 


Fig.  6-±. — Sponge  Tent. 


hours  after  the  introduction  of  a  single  laminaria  tent  into  the  uterus 
— agonizing  pain,  symptoms  of  collapse,  fainting,  etc.  Laminaria 
tents,  if  left  in  too  long  at  first,  are  apt  to  break,  and  their  extrac- 
tion, save  by  enlargement  of  the  cervical  canal,  has  proved  a  matter 
of  difficulty.  Sponge-tents  I  rarely  use  in  strictly  gynaecological 
work.  I  would  limit  their  employment  altogether  to  obstetric 
cases.  For  tupelo  it  is  claimed  that  it  is  cleaner  to  use,  not  so  apt 
to  break,  is  more  uniform  in  its  gradiial  enlargement  in  the  uterus, 
and  easier  of  removal ;  its  power  of  absorption  is  greater,  and  hence 
its  action  is  more  rajjid.  I  have  constantly  employed  it,  but  of  late 
years  only  use  laminaria. 


Forceps  for  inteoducing  Tents. 


Any  long  forceps  ■will  answer.  When  the  uterus  is  drawn  down  with  the  hook 
or  vulsellum  the  tent  can  be  introduced  with  the  hand.  The  forceps  also 
answers  admirably  for  carrying  gauze  into  the  uterine  canal. 

Some  special  rules  should  be  adhered  to  in  the  use  of  tents;     Do  not  insert 
them  immediately  before  a  menstrual  period,  nor  leave  them  in  longer  than 
*  Greely,  Annals  Gyn.  and  Fed.,  October,  1903. 


FIIiST  STEPS   OF  KXAMIXATIOX   OF  A    CASE. 


81 


twelve  honrs  (sponge-tents  not  over  six  hours),  and  never  for  this  length  of 
time  without  visiting  tlie  patient.  On  no  pretext  leave  a  patient  for  a  night 
or  a  clay,  with  a  tent  in  utero,  without  assistance  being  within  reach  if  required. 
Bromide  of  ammonium  (20-30  grains)  or  liromide  of  potassium  should  be 
given  at  night  when  dilating  with  a  tent.  Let  the  patient  lie  in  bed  when 
the  tent  has  been  inserted.  Force  should  not  be  used  in  the  inti'oduction  of 
tents,  and  great  care  be  taken  when  there  is  any  history  of  recent  peri- 
metritis, or  in  2xitients  prone  to  peritoneal  inflammations.  At  all  times  an 
intelhgent  attendant  should  be  left  with  the  case  after  a  tent  is  placed  in 
utero.  Anticipate  any  septic  consequences,  so  far  as  is  possible,  by  the  use 
of  antiseptic  tents  (see  chapter  on  Asepsis,  etc.,  for  the  preparation  of  lami- 
naria  tents),  taken  from  a  solution  of  iodoform  and  ether.  To  introduce  a 
tent,  we  place  the  patient  in  the  dorsal  position  {having  taken  all  the  pre- 
liminary precautions  for  rendering  the  vagina-  aseptic).  The  uterus  is 
steadied  with  a  hook  or  tenaculum  ;  and  the  tent,  slightly  curved,  is  intro- 


FiG.  66.— XAxruAL  Size  of  Two  of  the  Smaller  Lajltn-aria  Texts  used 

BY  Author,  takex  out  of  Iodoform  axd  Ether. 

They  are  easily  bent  to  any  curve  we  require.     (See  chapter  on  '  Asepsis.') 

duced  with  a  long  forceps.  A  tampon  of  sterilized  iodoform  gauze  is  loosely 
packed  in  over  the  protruding  tent.  If  any  difficulty  be  experienced,  the 
uterus  should  be  drawn  well  down  and  fixed  with  the  tenaculum,  so  as  to 
obtain  steady  control  over  it. 

Forcible  Dilatation  may  be  carried  out  by  any  of  the  different  forms  of 
dilators  which  have  been  devised  for  this  purpose.  In  Hegar's  (Kumerle, 
Freiburg)  dilators  the  size  of  each  is  marked  on  the  short  handle  of  the 
bougie.  It  is  simply  catheterization  of  the  canal  by  short  ebonite  bougies. 
I  have  had  specially  made  for  the  same  purpose,  and  find  they  answer  much 
better,  conical  metal  bougies  of  aluminium,  varying  in  their  longest  circum- 
ference from  11  millimetres  to  59 ;  but  they  may  with  benefit  be  two  sizes 
larger  than  this  last  diameter.  They  have  a  bulbous  point,  with  a  short 
neck,  which  gradually  expands  into  a  belly.  The  curve  of  the  bougie  is  a 
circle,  having  a  diameter  of  25  centimetres.  In  using  these  bougies  it  is  well 
to  have  the  patient  in  the  dorsal  position  and  dravm  well  down  to  the  edge 
of  the  table.  The  metal  can  always  be  kept  smooth  and  bright,  and,  when 
oiled,  slips  with  slight  force  through  the  cervical  canal.  If  the  uterine  canal 
be  partially  dilated  by  tent  previously,  the  requisite  degi'ee  of  full  dilatation 
can  afterwards  be  easily  obtained  with  a  suitable  metal  or  vulcanite  dilator. 
There  Ls  no  risk  of  any  '  disastrous  consequences,'  unless  rash,  unwarrantable 
force  be  employed.     The  dUators  of  Leiter  I  prefer  to  those  of  Hegar. 

Expanding  and  Irrigating  Dilators. — Several  varieties  of  expanding  and 
irrigating  dilators,  rarely  if  ever  used  by  any   experienced  gynaecologists, 

G 


82 


DISEASES   OF    WOMEN. 


have  been  devised  with  considerable  ingenuity,  as  in  the  case  of  curettes. 
In  previous  editions  I  have  figured  several  of  these.  They  are  absolutely 
unnecessary,  and  are  more  ornamental  than  useful,  the  dilators  and  methods 
of  dilatation  described  being  quite  sufficient  for  every  purpose. 


C5 


^ 


Fig  7U  — (-  \^L_^or  Slven  BouGits. 
14  sizes  graduated  in  millimetres. 


I 


CHAPTER    III. 

FIRST   STEPS    OF   EXAMINATION    OF    A    CASE 

(continued). 

Mode  of  Examination. — I  now  assume  that  a  pelvic,  ovarian,  or 
uterine  case,  as  pelvic  htematocele,  ovarian  or  adnexal  tumour,  or 
fibrocyst  of  the  uterus,  is  brought  for  examination.  Let  us  proceed 
to  exhaust  the  means  at  our  disposal,  so  as  to  arrive  at  a  correct 
diagnosis.  We  have  inquii'ed  into  the  previous  history,  the  char- 
acter of  the  menstrual  secretion,  and  the  action  of  bowel  and 
kidney ;  we  have  taken  the  temperature  and  pulse.  We  note  the 
woman's  countenance — if  cheerful  and  hopeful,  or  expressive  of  pain 
and  anxious ;  if  emaciated  or  cachectic  ;  if  characterized  by  the 
fades  ovariana.  There  is  in  ovarian  dropsy  a  strange  mingling  of 
facial  emaciation  with  anxiety  of  the  countenance,  often  out  of  all 
proportion  to  the  interruption  of  the  general  health ;  it  is  altogether 
different  to  the  countenance  of  pregnancy,  and  quite  distinct  from  the 
cachexia  of  ordinary  malignant  disease.  This  appearance,  however, 
we  must  remember,  is  influenced  by  complications,  such  as  phthisis, 
hepatic  or  renal  disease,  pregnancy,  or  malignant  disease  of  the 
ovary.  But  in  hepatic  and  renal  disease  we  have  other  evidence 
— such  as  anasarca,  icterus,  distended  abdominal  veins,  oedema 
of  the  face,  hands,  or  feet,  albuminuria,  and  perhaps  cardiac 
complication — to  indicate  the  cause  of  the  distension. 

We  now  proceed  to  examine  the  abdomeru  I  cannot  insist  too 
emphatically  on  the  care  with  which  we  should  explore  it  before  we 
proceed  to  any  internal  examination. 

Examination  of  Abdomen. 

Its  Shape. — We  notice  if  it  be  barrel-shaped  and  arched,  as  in 
ovarian  dropsy,  or  if  the  swelling  be  unilateral  or  uniform ;  if  the 
sides  bulge,  more  or  less,  as  in  ascites,  or  if  the  tumour  be  evidently 
central,  and  if  its  ratio  of  increase  has  been  regularly  pi'ogressive, 


84  DISEASES   OF    WOMEN. 


as  in  pregnancy ;  if  there  be  distinct  swellings  in  different  regions, 
and  the  surface  of  the  abdomen  be  irregular  in  outline,  as  in 
multilocular  cysts,  malignant  solid  growths,  or  tumours  of  the  liver 
and  spleen. 

The  Umbilicus. — Examine  if  it  be  prominent,  as  in  pregnancy ; 
bulging  and  watery-looking,  as  in  ascites  ;  drawn  in,  as  in  solid 
tumours  with  adhesions,  and  in  malignant  cases. 

The  Appearance  of  the  Skin. — If  tense  and  thin,  showing 'the 
prominent  recti  muscles  underneath  ;  or  cedematous,  with  a  character- 
istic watery  appearance ;  if  it  be  laden  with  fat ;  if  marked  with 
linefe  albicantes,  cracks,  scars,  maculae,  or  any  cutaneous  eruption. 

Measurements. — In  ovarian  dropsy  the  greatest  circular  measure- 
ment is  at  the  umbilicus  (more  likely  it  is  below  it  in  ascites). 
Take  lateral  measurements  to  determine  the  symmetrical  nature  of 
the  growth.  During  the  early  months  of  growth  of  an  ovarian  cyst 
these  are  asymmetrical ;  they  are  symmetrical  in  pregnancy. 

Palpation. — Nothing  save  experience  in  educating  the  finger  to 
diiFerentiate  the  various  forms  of  tumours,  solid  and  fluid,  and  any 
enlargements  of  the  abdominal  and  pelvic  viscera,  can  teach 
abdominal  palpation.  It  is  not  to  be  learned  by  any  verbal  descrip- 
tion. The  size  of  an  organ,  the  extent  of  an  enlargement,  the 
degree  of  hardness  or  softness,  the  character  and  extent  of  fluctu- 
ation, the  nature  and  direction  of  the  pain  caused  by  pressure,  the 
appearance  of  the  fluctuating  wave,  and  the  sensation  of  superfici- 
ality or  depth  conveyed  to  the  hand  when  testing  the  abdomen  for 
this  sign — all  have  to  be  kept  in  mind  in  palpation.  A  few  direc- 
tions may,  however,  be  of  service.  Have  the  patient's  head  and 
shoulders  supported  with  a  pillow  ;  let  the  surface  of  the  abdomen 
from  the  sternum  to  the  pubes  be  exposed  ;  stand  facing  the  patient, 
and  lay  the  palms  of  the  hands  lightly  on  the  abdominal  wall ; 
gradually  pass  the  hands  over  the  various  abdominal  regions,  hypo- 
chondriac, epigastric,  lumbar,  umbilical,  inguinal,  and  hypogastric. 
With  the  fingers  explore  these  spaces  carefully ;  watch  the  patient's 
countenance  for  indications  of  shrinking  or  pain ;  define  as  far  as 
possible  the  limits  of  any  growth,  the  region  it  occupies,  its  connec- 
tion with  surrounding  viscera,  if  it  be  fixed  or  movable,  if  hard  or 
nodular,  if  soft  or  fluctuating  ;  get  the  character  of  the  fluctuation, 
if  superficial  or  deep-seated ;  carefully  examine  for  mobile  or  float- 
ing kidney.  Now  lay  the  hand  on  one  side  of  the  abdomen,  and 
tap  lightly  with  the  fingers  on  the  opposite  side,  and  feel  the  nature 
of  the  transmitted  wave  ;  judge,  by  watching  its  movement  under 


FIRST  STEPS  OF  EXAMINATION   OF  A   CASE.  85 


the  skin,  of  its  depth  (deeper  wave  in  ovarian  dropsy),  and,  by  its 
freedom  of  motion  in  all  directions,  of  the  character  of  the  cyst  in 
which  it  is  confined,  unilocular  or  multilocular,  and  if  the  fluid  itself 
be  encysted,  circumscribed,  or  free. 

It  is  quite  possible  ia  a  very  fat  patient  to  mistake  the  '  fat-thrill  '  for 
fluctuation.  '  To  muffle  this,'  says  Goodell,  '  I  ask  one  of  my  assistants  to 
lay  the  ulnar  edge  of  his  hand  along  the  linea  alba.  The  pressure  of  the 
hand  will  act  esactlj-  like  the  damper-wedge  of  the  piano-tuner,  which 
muflQes  the  sound  of  one  string  while  its  fellow  is  being  tuned.  By  this 
means  I  get  the  wave-tap  of  a  fluid,  and  am  enabled  unhesitatingly  to  sav 
that  there  is  a  liquid  collection  in  the  abdominal  cavity.'  Thus  a  fat 
abdominal  wall  may  completely  obscure  the  diagnostic  aid  we  obtain  from 
our  sense  of  touch,  and  has  doubtless  led  to  many  of  the  errors  of  practice, 
recorded  and  imrecorded,  in  the  operative  interference  with  abdominal 
enlargement. 

Percussion. — We  require  to  distinguish  the  relative  degrees  of 
dukiess  or  resonance  in  the  different  regions,  above  the  umbilicus, 
below  it,  and  in  either  flank,  and  in  the  influence  of  posture  on  the 
percussion  note.  The  rule  is,  that  ascitic  fluid  falls  with  gi'a\-ity 
(if  the  fluid  be  free  in  the  peritoneal  cavity,  and  not  restrained  by 
adhesion)  into  the  most  dependent  position,  which  is,  in  the  sitting 
position,  the  lower  zone  of  the  abdomen,  and  in  the  recumbent 
posture  the  flanks.     Hence  these  regions  will  give  a  dull  note. 

In  ovaiian  dropsy,  on  the  other  hand,  the  cyst  rising  up  from  the 
pehds  is  in  front  of  the  intestines,  which  are  displaced  to  either  side, 
so  that  the  anterior  surface  of  the  abdominal  wall  yields  a  dull 
sound  and  the  flanks  are  resonant.  Nor,  as  a  rule,  is  the  dulness 
changeable  with  posture,  and  never  to  the  same  extent  as  in  com- 
plicated ascites.  The  complication  of  pregnancy  with  ascites  or 
hydramnios,  of  ovarian  dropsy  with  pregnancy,  ascites,  or  cysts  of 
the  liver  or  kidney,  all  of  which  we  occasionally  find,  compel  us  to 
be  very  cautious  in  placing  reliance  on  percussion  in  diagnosis. 

Auscultation, — The  abdomen  must  be  most  cautiously  examined  for  the 
different  conditions  Hkely  to  be  confounded  vnXh.  pregnancy.  It  requires 
occasionally  most  patient  and  careful  listening  to  detect  the  fostal  heart-sounds, 
especially  if  there  be  a  rather  fat  abdomen,  any  ascitic  fluid  in  the  peritoneum, 
or  hydramnios,  and  if  the  foetal  pulsations  be  weak  and  rapid.  We  have  to 
be  careful  not  to  fall  into  an  en-or  that  I  have  known  occur  with  regard  to  a 
patient  Avith  a  very  rapid  pulse,  who  suffered  from  an  abdominal  tumour 
which  proved  to  be  fibroid.  The  rapid  aortic  pulsations  were  transmitted  to 
the  tumour,  and  an  opinion  was  consequently  formed  that  the  woman  was 
pregnant.     We  must  guard  ourselves  against  the  possibility  of  error,  in  cases 


86  DISEASES   OF   WOMEN. 


of  assumed  pregnancy,  by  the  use  of  an  ansesthetic  in  the  determination  of  a 
doubtful  case,  and  to  exclude  the  presence  of  a  phantom  tumour. 

Vaginal  Examination. — We  now  proceed  to  make  a  vaginal  ex- 
amination. Whenever  possible,  an  enema  should  be  administered 
previously,  and  the  rectum  emptied.  The  patient  may  be  in  the 
lateral  or  dorsal  position — preferably  the  latter.  It  is  well  on 
separating  the  labia,  to  inspect  the  vulva  for  any  swelling,  excoria- 
tion, discharge,  sores,  or  tumours,  at  the  same  time  marking  the 
appearance  of  the  clitoris,  urethral  orifice,  hymen  (if  present),  and 
fourchette.  Moistening  the  finger — the  nail  of  which  should  always 
be  pared  close — with  an  antiseptic  cream,*  we  carry  it  gently  into 
the  vagina,  noting  the  temperature  of  the  latter.  Reaching  the 
uterus,  we  examine  the  condition  of  the  os  uteri,  its  shape  and  size, 
if  normal,  or  abraded,  soft,  patulous,  or  fissured.  The  cervix  uteri 
is  next  examined,  as  to  its  position,  shape,  length,  and  degree  of 
hardness.  Placing  the  finger  firmly  on  the  cervix,  we  estimate  by 
pressure  the  mobility  of  the  uterus.  At  the  same  time  we  contrast 
the  anterior  and  posterior  wall  of  the  cervix,  examine  for  any  sulcus 
in  the  uterus,  any  special  hardness  in  the  uterine  wall,  or  any  fibroid 
which  may  here  be  developing.  The  finger  is  now  swept,  com- 
mencing anteriorly,  round  the  vaginal  roof,  and  any  fulness, 
contraction,  hardness,  or  swelling  is  detected  and  examined.  The 
degree  of  tightness  or  stretching  of  the  vaginal  roof  is  estimated. 
We  next  pass  to  the  posterior  aspect  of  the  uterus,  and  explore  the 
utero-rectal  space  and  the  pouch  of  Douglas.  In  this  latter  space 
we  may  find  a  tumour,  ovarian  cyst,  a  faecal  accumulation,  some 
cellular  and  peritoneal  effusion,  the  fundus  of  a  retroverted  uterus, 
or  a  prolapsed  ovary.  We  take  advantage  of  the  act  of  respiration 
and  the  influence  of  the  diaphragm  on  the  pelvic  viscera,  by  direct- 
ing the  patient  during  this  examin,ation  to  draw  a  few  deep  inspira- 
tions, followed  by  prolonged  expirations.  This  will  help  to  bring 
the  ovary  more  within  reach  of  the  finger.  In  many  cases,  by 
directing  the  woman  to  lie  towards  the  opposite  side  to  that  of  the 
ovary  we  wish  to  examine,  and  by  passing  the  forefinger  (that  of 
the  right  hand  for  the  left  ovary)  up  to  the  vaginal  roof,  while  with 
the  fingers  of  the  other  hand  we  firmly  depress  the  abdominal  wall 
into  the  pelvis,  we  can  get  the  ovary  between  the  fingers  and  define 
its  limits  and  also  trace  the  Fallopian  tube  for  its  entire  extent. 

*  A  tube  should  be  used,  not  a  crock,  so  that  a  fresh  supply  may  be  bad  at 
each  examination,  and  the  risk  of  contamination  avoided. 


FIRST  STEPS   OF  EXAMINATION   OF  A   CASE.  87 

While  thus  examining,  we  do  not  forget  the  possible  presence  of 
stone  in  the  bladder,  which  may  be  detected  through  the  vaginal 
wall  in  front.  Before  withdrawing  the  finger  we  satisfy  ourselves 
thoroughly  as  to  the  character  of  recent  effusions,  the  size  of  the 
ovaries,  or  if  the  remains  of  any  old  effusion  occupy  the  cellular 
tissue,  or  be  inside  the  peritoueimi. 

Conjoined  Examination. — This  we  carry  out  either  by  the  two 
hands  or  by  the  sound  and  hand. 

I  Abdomino- vaginal . 
Recto-abdom  inal . 
Recto-vaginal. 
i  Titer  o-abdominal . 
Utero-rectal, 
Kecto-vesical. 

Abdomino-vaginal. — We  want  to  ascertain  the  size  of  the  uterus, 
its  degree  of  mobility,  its  sensitiveness  ;  the  condition  of  the  bladder 
ovaries,  and  broad  ligaments.  We  do  this  in  the  most  satisfactory 
manner  by  placing  the  fingers  of  one  hand  on  the  abdominal  wall 
a,bove  the  pubes,  and  the  first  or  two  fingers  of  the  other  in  the 
vagina,  resting  on  the  cervix,  thus  getting  the  organ  between  the 
two  hands.  In  every  case  of  obscure  uterine  affection,  when  we 
wish  to  know  accurately  the  volume  of  the  uterus  and  its  relative 
increase  in  size,  this  is  an  indispensable  step  in  our  examination. 
We  cannot  too  strongly  urge  the  importance  of  this  method  of 
examination  in  palpating  the  ovaries.  '  The  invagination  of  the 
pehdc  floor  is  of  the  utmost  importance,  as  by  this  means  the  ex- 
a>mining  finger  is  practically  lengthened  by  the  amount  of  the 
invagination,  or,  what  is  the  same  thing,  the  vagina  is  shortened  ' 
(Kelly).*  The  patient  having  been  antesthetized  and  drawn  well  to 
the  edge  of  the  couch,  with  the  thighs  held  apart  by  the  assistant 
or  nurse,  or  supported  in  leg-rests,  such  an  examination  cannot  fail 
to  reveal  the  true  state  of  the  uterus  and  adnexa.  We  can  then 
reach  higher  up  in  the  pelvis,  and  gain  more  complete  information 
by  the  introduction  of  both  the  fore  and  middle  fingers. 

Recto-abdominal. — Withdrawing  the  finger  from  the  vagina  and 
again  anointing  the  surface,  we  pass  it  gently  into  the  rectum.  In 
doing  so,  we  reach,  unless  the  uterus  be  retroverted,  the  cervix 
uteri,  and  feel  it  prominent  through  the  anterior  wall  of  the  rectum. 
Depressing  the  uterus  well  with  the  fingers  on  the  abdomen,  we  now 
*  See  p.  59,  Fig.  34. 


DISEASES   OF   WOMEN. 


reach  the  ovaries,  which  can  again  be  explored,  and  their  size  and 
sensitiveness  ascertained.  We  may  also  satisfy  ourselves  of  the 
volume  and  position  of  the  uterus,  of  the  dimensions  of  a  fibroid. 
We  likewise  judge  of  the  degree  of  congestion  of  the  rectal  mucous 
membrane,  and  the  extent  to  which  the  rectum  is  interfered  with 
either  by  cellular  effusions,  collections  of  fluid  in  Douglas'  space,  or 
a  retroverted  uterus. 

Recto-vaginal. — Still  keeping  the  finger  in  the  rectum,  we  insert 
the  index-finger  of  the  other  hand  into  the  vagina.     Examination 

of  the  rectum  often  gives  such  distress 
to  the  patient,  that  the  less  frequently 
we  introduce  the  finger  into  it  the  better. 
Therefore,  I  generally  prefer  to  use  the 
index-finger  of  the  right  hand  in  the 
vagina,  the  woman  lying  on  her  back^ 
the  left  forefinger  remaining  in  the  rec- 
tum. We  can  thus  in  the  best  manner 
determine  the  state  of  the  rectum,  the 
utero-rectal  space,  the  position  and  size 
of  the  ovaries,  and  the  character  of  any 
tumour,  swelling,  or  efi'usion  between  the 
uterus  and  rectum. 

RectO-vesical. — If  there  be  any  doubt 
which  the  uterine  sound  may  remove, 
we  slip  it  into  the  bladder  while  we 
retain  the  finger  in  the  rectum.  We 
thus  are  enabled  to  judge  of  the  position  and  size  of  the  uterus  in 
fat  women,  in  whom  palpation  is  difficult,  determine  the  presence  of 
the  uterus  in  atresia  of  the  vagina,  of  its  absence  in  inversion,  and  to 
diagnose  between  inversion  and  polypus.  While  the  sound  is  in  the 
bladder,  if  there  be  vesical  irritation,  we  judge  of  its  capacity,  how  far 
it  is  encroached  on  by  the  uterus,  and  exclude  the  existence  of  stone,* 
Utero-abdominal.— Should  we  determine  to  use  the  sound  we 
may  by  its  means  judge  of  the  position,  mobility,  and  length  of  the 
uterine  cavity,  or  of  any  obstruction.  In  doing  this  we  place  the 
right  hand  over  the  pubes  and  manipulate  the  uterus  on  the  sound. 
In  diagnosing  the  relations  of  abdominal  tumours,  their  connection 
with  the  uterus,  and  the  extent  to  which  the  uterus  is  involved 
by  fibroid  growths,  or  polypus,  the  utero-abdominal  method  will 
occasionally  be  found  to  give  valuable  assistance. 

*  See  pag.e  7.S. 


Fig.  71. — Kecto-vesical  Ex- 
amination IN  Complete 
Inversion  op  the  Uterus. 


FIRST  STEPS  OF  EXAMINATION  OF  A    CASE.  89 

Utero-rectal. — Still  retaining  the  sound  in  the  uterus  and  passing 
the  linger  into  the  rectum,  we  can  in  a  similar  manner  examine  the 
posterior  wall  of  the  uterus,  judge  of  the  intramural  fibroids,  any 
adhesions  posteriorly  the  degree  of  retroversion,  how  far  the  uterus 
is  fixed  by  any  effusion,  and  to  what  extent  its  freedom  of  move- 
ment is  limited, 

Other  Steps. — In  a  large  proportion  of  cases  the  examination  just 
detailed,  in  part  or  whole,  will  enable  us  to  arrive  at  a  conclusion 
as  to  the  nature  of  a  case.  It  may,  however,  happen  that  doubt 
still  remains.  There  is  some  discharge  from  the  uterus,  and  we 
have  to  satisfy  ourselves  as  to  its  source  and  nature.  On  examina- 
tion with  the  finger,  the  feeling  of  the  os  uteri  and  cervix  prompts 
us  to  use  the  speculum.  An  abdominal  tumour  exists,  regarding 
the  exact  nature  of  which,  or  its  contents,  we  are  not  perfectly 
satisfied.  There  is  a  quantity  of  abdominal  fat  or  tympanitic  dis- 
tension of  the  abdomen,  or  the  difficulty  of  making  a  satisfactory 
examination  of  the  patient  has  been  great.  This  difiiculty  may  also 
result  from  nervousness,  or  sensitiveness  and  tenderness  of  the  vagina. 
In  all  such  cases  an  anaesthetic  is  indispensable. 

Speculum. — In  the  case  of  discharge,  we  use  the  speculum  to 
examine  the  os  uteri,  and  judge  of  its  source  and  nature.  Also  it 
may  be  requisite  to  see  the  vaginal  walls ;  if  they  be  stripped  of 
epithelium,  or  granular  and  secreting  a  quantity  of  vaginal  mucus. 

A  beginner  may  have  some  diflficulty  in  passing  the  sound  in  the  usual 
manner  into  the  uterus.  By  placing  the  patient  in  tlie  semi-prone  position 
and  using  Sims'  speculum,  he  can  generally  do  so  with  ease.  Or  if  she  lie  on 
her  back,  and  a  tubular  speculum  be  inserted,  he  can  bring  the  os  uteri  into 
view ;  and  then,  if  the  uterus  be  in  its  normal  position  or  anteverted,  by 
dipping  the  sound  well  down,  he  can,  unless  there  be  some  obstruction,  pass 
it  on  into  the  cavity.     (See  remarks  on  the  '  Uterine  Sound,'  Chap.  II.) 

Tents. — A  tent  or  uterine  dilator  may  have  to  be  employed,  if  we 
desire  to  explore  the  uterine  canal  in  cases  of  suspicious  and  pro- 
longed haemorrhage,  when  we  suspect  intra-uterine  or  placental 
polypi,  or  where  there  is  septic  discharge,  the  consequence  of  any 
intra-uterine  decomposition. 

Aspiration. — We  may  draw  ofi"  a  small  quantity  of  fluid  from  a 
doubtful  abdominal  swelling,  to  determine  its  nature  by  chemical  or 
microscopical  tests  ;  this  may  be  done  with  the  ordinary  hypodermic 
syringe  or  aspirating  needle.  The  aspirator  is  specially  useful  for 
diagnosis  in  doubtful  pelvic  and  uterine  enlargements,  such  as  retro- 


90 


DISEASES    OF    WOMEN. 


hsematocele,  cystic  tumours  in.  Douglas'  space,   pelvic  peritonitis, 
and  retained  menses. 

An  Aspirating  Needle  or  subcutaneous  syringe  is  often  required 
to  remove  a  little  of  the  fluid  in  abdominal  and  pelvic  tumours, 


Fig.  72. — Bartlett's  Aspirator,  most  useful  in  Exploeation. 


Fig.  73. — Aspirator.    (Matthews  Brothers.) 

This  is  a  most  handy  and   simple  appliance,  and,  together  with  the  set  of 
guarded  needles  and  obturators  furnished  with  it,  answers  every  purpose. 


Fig.  74. — Aspirating  Needles. 


in   order   to   ascertain  its   nature    by  chemical    and    microscopical 
examination.     We  may  draw  the  fluid  from  the  point  of  greatest 


FIJiST  STEPS   OF  EXAMINATION   OF  A    CASE.  91 


distension — either  vagina,  rectum,  oi'  abdomen.  The  small  exploring 
aspirator  of  Bartlett  will  be  found  very  useful  in  the  exploration  of 
small  cysts,  and  for  purposes  of  diagnosis. 

The  Sound  and  Anaesthesia. — I  have  already  said  tliat  the  more  expe- 
rienced our  tactile  sense  liecomes,  the  less  we  re([uire  to  use  either  sound  or 
aspirator,  or  even  tlie  speculum,  in  diagnosis.  Careful  digital  examination, 
aided  by  palpation,  and  by  taking  advantage  of  posture,  is  generally  sufficient 
to  enable  us  to  come  to  a  correct  conclusion.  But  in  all  cases  of  doubt  and 
difficulty  it  is  better  to  exhaust  the  means  of  examination  than  to  commit  an 
error  ia  diagnosis.  To  no  aid  in  examination  does  this  remark  apply  more 
than  to  the  use  of  an  anfesthetic.  We  do  not  avail  ourselves  as  often  as  we 
should  of  anaesthesia  in  the  elucidation  of  difficult  questions  arising  in  connec- 
tion with  complicated  and  obscure  abdominal  cases.  It  is  not  too  much  to  say 
that  ha  any  such  no  final  verdict  should  be  given  without  its  help. 

It  is  in  those  cases  in  which  difficulties  arise,  either  from  the  quantity  of 
fat  in  the  abdominal  cavity  or  gaseous  distension  in  the  bowel,  where  there 
is  great  pain  and  sensitiveness  on  the  least  attempt  at  examination,  or 
when  a  patient  is  debihtated  or  weakened  by  previous  prolonged  suffering, 
that  an  anajsthetic  is  specially  called  for.  In  children  and  young  girls  an 
anijesthetic  is  often  essential  in  order  to  make  a  thorough  examination. 
Cocaine  may  be  used,  but  I  prefer,  for  complete  examination,  when  any 
ansesthetic  is  required,  either  ether  or  chloroform.  I  feel  confident  that 
many  errors  of  diagnosis  would  be  avoided  if  we  more  frequently  had  resort 
to  anaesthetics  in  examination  of  the  abdomen  and  pelvis. 

Rectal  Exploration  (Simon's  Method). — This  plan  of  exploration  of 
the  abdominal  viscera  is  seldom  practised  in  this  country.  In  the 
instance  of  a  mesenteric  mass  causing  partial  ascites  and  abdominal 
enlargement,  I  was  enabled,  by  rectal  palpation  of  the  pelvic  viscera, 
to  arrive  at  a  diagnosis.  The  woman  should  be  fully  ansesthetized. 
She  is  placed  in  the  lithotomy  position,  her  thighs  are  well  drawn 
up  to  the  abdomen  ;  the  sphincter  ani  is  then  thoroughly  dilated  by 
the  fingers,  or,  better,  by  the  thumbs ;  gradually  the  hand,  well 
oiled,  in  the  form  of  a  cone,  is  most  cautiously  introduced  in  a 
rotary  fashion ;  when  the  hand  has  passed  into  the  bowel,  the 
fingers  can  be  separated  a  little  so  as  to  explore  the  pelvic  organs ; 
two  fingers  may  be  passed  on  into  the  sigmoid  flexure  of  the  colon. 
My  hand  measures,  at  the  line  of  its  greatest  circumference,  eight 
inches.  I  have  thus  introduced  it  without  lacerating  the  anus. 
This  is  not  the  rule ;  even  with  the  greatest  care  and  a  small  hand, 
some  sphincter  fibres  will  be  ruptured,  and  in  some  patients  it  is 
impossible  to  introduce  the  hand  without  serious  injury  to  the 
sphincters  and  bowel.  In  ordinary  dilation  of  the  sphincters  for 
obstinate  costiveness  it  is  not  necessary  to  introduce  the  hand.     It 


92  DISEASES   OF    WOMEN. 

is  superfluous  to  point  out  how  cautious  must  be  the  manner  in 
which  this  procedure  is  conducted,  and  how  seldom  it  is  needful, 
considering  the  other  means  of  diagnosis  at  our  disposal.  I  may 
here  draw  attention  to  the  methods  of  exploration  adopted  by 
Professors  Naunyn  and  Ewald,  the  former  injecting  and  filling 
the  colon  with  water  by  the  syphon  plan,  the  latter  inflating  the 
intestines  with  air,  so  as  to  make  the  situation  and  relation  of 
tumours  to  or  in  the  abdominal  viscera  and  intestines  clear. 

The  Pelvic  Organs  in  Children. 

Value  of  Rectal  Exploration  in  Children. — George  Carpenter,  of  the 
Evelina  Hospital  for  Sick  Children,  has  written  some  important  communica- 
tions on  the  value  of  rectal  examinations  iu  the  diagnosis  of  pelvic  disease  in 
children,  instancing  several  cases  in  which  grave  conditions  were  discovered 
through  combined  rectal  and  abdominal  examination  by  means  of  ansesthesia. 
The  patient's  legs  are  well  drawn  up,  and  the  thighs  are  flexed  on  the  abdomen. 
The  pelvis  is  raised  on  a  cushion,  and,  with  the  left  hand  placed  on  the  abdomen, 
the  right  side  of  the  abdominal  cavity  is  explored  with  the  right  index-finger. 
The  hands  are  reversed  to  examine  the  left  side.  The  bowel  and  bladder 
have  been  previously  emptied.  The  author  has  thus  been  able  to  diagnose 
and  map  out  the  position  of  a  horseshoe  kidney.  By  this  means  the  appendix, 
the  iliac  fossa,  the  uterus  and  adnexa,  may  be  explored,  and  the  position  of 
tumours  or  collections  of  fluid  determined.  Carpenter's  remarks  on  the 
relations  and  dimensions  of  the  female  pelvic  organs  in  children  are  of 
importance. 

'  The  sacrum  in  children  is  almost  straight,  and  so  is  the  rectum,  the 
direction  of  the  bowels  being  probably  influenced  by  that  of  the  bone.  The 
infantile  bladder  is  egg-shaped,  with  the  larger  end  downwards,  and  as  the 
pelvis  is  shaUow,  it  is  almost  entirely  an  abdominal  organ ;  but  as  soon  as 
the  chUd  begins  to  walk  the  bladder  sinks  more  into  the  pelvis,  though  even 
then  its  attachments  are  so  loose  that  it  readily  rises  wholly  into  the  abdo- 
minal caAdty  when  distended  or  otherwise  displaced,  a  feature  observed  until 
puberty  is  near  at  hand.  The  uterus  in  the  child  is  almost  entirely  made  up 
of  cervix,  there  being  very  little  body,  and  it  lies  in  the  upper  part  of  the 
pelvis.  At  birth  the  ovaries  have  descended  as  far  as  the  brim  of  the  true 
pelvis,  but  in  children  a  few  weeks  old  they  are  found  close  to  the  external 
iliac  arteries  at  the  side  of  the  pelvis. 

'  I  have  found,  however,  the  uterus  and  appendages  well  above  the  brim 
of  the  pelvis  on  making  a  rectal  examination  in  a  child  seven  months  old. 
Fig.  75  is  a  sketch  of  the  tubes  and  ovaries  of  a  child  aged  two  years  and 
four  months  that  I  made  ad  naturam,  which  shows  the  relative  positions. 
Another  sketch  gives  the  exact  size  of  these  organs  when  removed  from  the 
body.  It  wOl  be  seen  that  the  uterus  is  about  1  inch  long  and  h  inch  broad 
at  the  fundus,  the  tubes  about  1|  inches,  the  right  ovary  §  inch  in  length, 
and  the  left  J  inch  in  length,  and  each  about  ^  inch  in  diameter.     The 


Fll^Sr  STEPS   OF  EXAMINATION  OF  A    CASE. 


93 


ovaries  vary  in  size  from  j\  incli  long  by  I  inch  broad  in  a  child  a  few  weeks 
old,  to  organs  measuring  li  inches  by  h  inch  in  a  child  approaching  puberty. 
Intermediate  sizes  are  found  according  to  the  age  of  the  child,  but  ovaries 
show  some  variation  in  size  in  children  of  similar  ages.  The  organs  are  for 
the  most  part  elongated  oval  in  shape,  but  organs  that  are  more  or  less 


'Cy'.t^/#^"^    IrH^^^^-/ 


i!i  >.  i 


Fig.  75.— Genital  Okgaxs  kemoved  fkom  a  Female  Child,  aged  Two 
Years  Four  Months.     (George  Carpenter.) 

Vagina  opened  behind,  showing  the  external  os  uteri.     The  ureters  are  dimly 
outlined  on  either  side.     The  round  ligaments  are  ill  developed. 

round  are  occasionally  found,  and  one  ovarj'  is  not  infrequently  decidedlj'' 
larger  than  its  fellow.  The  Fallopian  tubes,  roughly  estimating  their 
diameter  for  chnical  purposes,  are  about  equal  to  the  vas  at  a  similar  age  at 
their  nan'owest  part,  but  they  gi-adualh'  enlarge  as  they  pass  along  to  the 
fimbriated  extremity ;  in  length  they  vary  from  a  little  over  1  inch  to  a  little 
over  3  inches,  according  to  the  age  of  the  patient.  The  important  anatomical 
guide  to  these  structures  when  making  a  rectal  examination  is  the  falciform 
ligament.  This  falciform  ligament,  or  the  utero-sacral  ligament,  if  that  term 
be  prefen-ed,  forms  a  sickle-shaped  curve  surrounding  the  rectum,  attached 
behind  to  the  sacrum,  and  in  front  to  the  lower  part  of  the  cervix.  This  is 
very  well  seen  in  both  drawings  (Figs.  75  and  76),  and  when  the  finger  has 
passed  some  little  distance  up  the  rectum,  its  shai-p  edge  is  readily  foimd. 
and  is  unmistakable.  Using  this  structure  as  a  guide,  the  tubes  and  ovaries, 
which,  as  the  drawing  (Fig.  76)  shows,  are  on  a  higher  plane,  can  be  readily 
manipulated  between  the  exploring  finger  and  the  bony  wall  of  the  pelvis,  or 
bimanually,  and  while  these  structures  are  being  examined,  the  ureters,  the 


94 


DISEASES   OF   WOMEN. 


right  being  shown  in  the  drawing  as  it  crosses  the  pelvis  and  disappears 
under  the  corresponding  tube  and  ovary,  can  be  examined. 

'  It  is  sometimes  possible  to  detect  in  the  ovaries  the  small  cysts  or  dropsical 
Graafian  follicles,  which  are  not  infrequently  found  post-mortem.  The  uterus, 
being  a  freely  movable  body,  is  not  easily  detected  in  this  way,  and  readilj^ 


Fig.  76. — Pelvic  Okgans  of  a  Female  Child,  aged  Two  Yeaes  Four  Months. 
(George  Carpenter.) 

F,  falciform  or  utero-sacral  ligaments ;  6,  right  ureter  ;  H,  rectum ;  K,  brim 
of  pelvis ;  L,  reflected  abdominal  wall. 

eludes  the  finger,  which  pushes  that  organ  before  it ;  but  by  a  bimanual 
examination  any  marked  abnormality  can  be  easily  appreciated,  if  the  bladder 
be  emptied.  In  young  children  the  uterus  can  be  rolled  between  the  finger 
and  the  symphysis  pubis,  and  its  contour  made  out  with  ease. 

Discharges. — In  inflammatory  states  of  the  female  genito-urinary 
organs,  the  nature  and  character  of  the  discharge  found,  on  vaginal 
examination,  coming  from  the  uterus,  or  in  the  vagina,  and  spon- 
taneously appearing  at  the  vulva,  is  of  considerable  moment  in  the 
diagnosis. 

The  following:  table  will  assist  the  student : — 


FIRST  STEPS   OF  KXAMIXATIOX  OF  A    CASE. 


95 


DISCHARGES. 


CHABACrrEK. 


Watery  (hydror- 
rh  seal)/  and 
mixed. 


SOURCE. 


Mucous  and  epi- ! 
thelial,  often  con- 1 
taining  epithelial 
debris,  oil  -  glo  - 
bules.  Fre- 
quently only 
physiological  ex- 
aggeration of  the 
normal  secretion, 
as  in  pregnancy, 
or  associated 
with  menstrua- 
tion. 


Uterus. — Accompanying  and 
following  pregnancy ;  asso- 
ciated with  malignant  dis- 
ease, hydatids. 

Vagina. — Vesico-vaginal  fis- 
tulse,  rupture  of  ovarian 
cyst.  Discharge  frequently 
physiological,  both  from 
uterus  and  vagina ;  the 
quantity  of  water  the  vagina 
can  secrete  is  shown  in  the 
profuse  discharge  after  a 
glycerine  plug  is  worn  in  it. 


APPEARANCE   AXD 
PROPERTIES. 


At  times  colourless,  or 
mixed  with  blood,  and 
with  cells  of  different 
kinds,  or  containing 
shreds  of  decomposing 
debiis,  or  hydatids,  or 
urine. 


Fallopian  tubes. 
Cavity  of  fundus  uteri. 
Carnal  of  cervix  uteri. 


External  surface  of  cervix  and 
the  lips  of  the  os  and  fundus 
of  the  vagina.  Seen  occa- 
sionally in  excess    during 

,  pregnancy. 


Whitish,  alkaline,  colum- 
nar epitheHum ;  at  times 
viscid,  like  unboiled 
white  of  e^g\  when 
aggravated,  fiUs  the  cer- 
vix and  OS  uteri  as  a 
tenacious  plug  most 
difficult  to  remove,  and 
is  quite  characteristic 
of  endometritis.  It  may 
be  the  cause  of  steiility. 
Where  the  secretion  is 
simply  increased,  and 
attends  corporeal  leu- 
con'hoea,  it  is  known 
as  the  "  whites,''  and 
is,  as  a  rule,  a  proof 
that  the  general  health 
is  suftering,  as  in  anae- 
mia, leukaemia,  and 
after  metronhagia. 
Acid  reaction ;  varies  in 
consistence — generally 
thick,  creamy,  white. 
I  or  yellowish  white,  ad- 
!  hering  often  closely  to 
'  the  OS  and  cervix  uteri, 
and  almost  membra- 
nous in  character ;  squa- 
mous epithelial  cells, 
oil-srlobules. 


96 


DISEASES   OF    WOMEN. 


Discharges  (continued). 


CHARACTER. 


Sebaceous,  readily 
becoming  puru- 
lent. 

Purulent. 


Hsemorrhagic  (ex- 
eluding  the 
haemorrhages  of 
pregnancy) . 


Some  portion  of  the  vagina. 


Vulva,  lahia,  vulvo-vaginal 
glands,  sebaceous  glands. 

Fallopian  tubes. — Pus  the  re- 
sult of  salpingitis. 

Uterus.  —  Any  part  of  the 
uterus,  mingled  with  mucus. 

Vagina. — Pus  may  find  its 
way  into  the  uterus  through 
fistulous  openings,  and  into 
the  vagina  either  by  the 
bursting  of  a  suppurating 
cyst  which  has  formed  ad- 
hesions, or  the  escape  of 
pus  from  a  pelvic  abscess, 
the  consequence  of  pelvic 
peritonitis,  or  a  pelvic 
hsematocele.  The  source 
of  this  pus  may  be  a  fis- 
tulous opening  from  the 
bladder  or  urethra  in  cases 
of  pyehtis  or  cj'stitis. 


Causes. 

Blood  may  pour  from  any 
portion  of  the  generative 
tract.  We  may  thus  clas- 
sify the  sources  of  the 
haemorrhage : 

Uterine. —  1.  Menstrual  or 
altered  menstrual  flow. 

2.  In  salpingitis;  metritis ; 
endometritis ;  glandular, 
granular,  fungous,  catarrhal 
cervicitis ;  laceration  of  the 
cervix  ;  syphilitic  disease ; 
malignant  disease ;  subin- 
volution ;  uterine  fibroid ; 
polypus  of  any  kind;  granu- 
lations;  vascular  tumours. 


APPEARANCE   AND 
PROPERTIES. 


Acid  mucus ;  character 
depends  on  the  nature 
of  inflammation;  con- 
tains at  times  parasites 
and  fungi — Trichomo- 
nas vaginalis ;  Lepto- 
thryx  buccalis. 

Acid  fatty  mucus,  oily  par- 
ticles, epithelial  cells. 

The  appearance  of  the 
purulent  secretion  will, 
in  great  measure,  de- 
pend on  its  source  and 
the  form  of  inflamma- 
tion that  has  produced 
it;  it  may  be  profuse 
and  thick,  scanty  and 
thin,  very  foetid  or  al- 
most odourless,  tinged 
with  blood  or  rusty- 
looking,  or  of  a  dirty 
greenish  colour. 

The  discharge  of  vaginitis 
is,  as  a  rule,  profuse, 
pouring  out  in  quan- 
tity, and,  especially  if 
it  be  gonorrhoeal,  thick, 
yellow,  and  persistent. 
It  is  mingled  with  epi- 
thelium. 


The  blood  may  be  arterial 
or  venous,  dependent 
upon  its  cause,  whether 
there  be  active  or  pas- 
sive congestion,  due  to 
direct  rupture  of  vessels 
from  ulceration  and 
slough,  or  their  injury 
by  laceration,  or  wounds 
of  any  kind.  In  the 
various  morbid  condi- 
tions of  the  blood,  and 
during  the  exanthe- 
mata, the  blood  poured 
out  is  generally  dark 
and    does  not  readily 


FIRST  STEPS  OF  EXAMIXATIOX   OF  A    CASE. 


97 


Discharges  {contimied~). 


CHAItACTEK. 


APPEAUANOE    AND 
PROPERTIES. 


llfemoiThagic 
{continued) — 


(2)  Hfemorrhage 
connected  with 
menstruation  and 
often  associated 
with  irregularity 
of  the  menstrual 
periods. 


(3)  Haemorrhage 
due  to  disease 
elsewhere. 


3.  Flexions  and  versions. 

4.  Traumatisms — opera- 
tions. 

5.  Ectoi)ic  gestation. 
Vagina. — Same  constitutional 

causes  as  produce  hfemor- 
rhage  from  the  vulva ; 
granulations  ;  abrasions ; 
ulceration;  varicose  states; 
thrombus;  traumatic 
causes ;  malignant  disease. 
Rectum. — Hfemorrhoids ;  con- 
gestion of  the  rectal  mucous 
membrane  ;  fissure ;  ulcer ; 
malignant  disease ;  trau- 
matic causes. 


Urethrce. — Caruncle,  various 
gi'owths,  traumatisms. 

Vulva ;  in  the  exanthemata 
—  (variola,  typhoid  and 
typhus  fevers,  measles) ; 
spinal  meningitis;  malig- 
nant ulceration ;  gangrene ; 
noma ;  thrombus,  varicose 
conditions ;  various  blood 
states,  as  in  leucocythaemia 
and  scurvy ;  in  the  hfemor- 
rhagic  diathesis;  wounds, 
operations,  coitus ;  from 
vascular  excrescences,  and 
tumours. 

1.  Simple  menorrhagia — phy- 
siological excess  attendant 
upon  ovulation ;  in  plethoric 
states  from  excess  of  coitus ; 
excessive  menstruation  at 
the  '  change  of  life ' — during 
the  menopause ;  from  sup- 
pressed skin  secretion — the 
result  of  cold  taken  previous 
to  or  during  menstruation. 

2.  Uterine  hsemorrhage  de- 
pendent upon  hepatic,  car- 
diac and  renal  affections ; 
in  phthisical  states. 


coagulate,  rendering  the 
ha3raorrhage  difficult  of 
suppression. 

The  blood  at  times  is 
mixed  with  menstrual 
discharge,  or  is  merely 
altered  menstrual  flow, 
excessive  in  quantity 
(menorrhagia)  ;  the 
blood  is  then  mixed 
with  the  debris  of  uter- 
ine tissue,  epithelial 
cells,  fatty  and  oil  par- 
ticles, mucous  corpus- 
cles, or  if  there  be 
ulceration,  pus,  and  the 
products  of  inflamma- 
tion. 


98 


DISEASES   OF   WOMEN. 


Discharges  {continued). 


CHAKACTEE. 


APPEARANCE   AND 
PROPERTIES. 


by  the  muscular 
action  of  the  va- 


Ak  (physometra).  j  Uterus  and  Vagina. — In  the 
The  air  is  expelled  ;  knee  and  elbow  position  air 
enters  the  vagn^na  more  or 
less  readily  when  the  va- 
ginal walls  separate ;  also 
in  the  semi-prone  position. 
Air  may  accumulate  when 
a  pessary  is  worn,  if  there 
be  a  fistulous  communica- 
tion with  the  bowel,  or  in 
prolapsus  uteri. 


Fistula. — Most  careful  exploration  of  the  vagina,  uterus,  and 
rectum  is  necessary  in  order  to  detect  a  minute  fistulous  communi- 
cation of  the  vagina  with  the  bowel,  or  of  the  uterus  with  either 
the  bowel  or  bladder.  The  injection  of  a  little  mUk  or  coloured 
fluid  may  assist  in  the  detection. 

The  Microscope. — We  bring  the  microscope  to  our  assistance  in 
the  examination  of  suspicious  discharges  ;  in  determining  the  nature 
of  the  cells  contained  in  cysts — ovarian,  hydatid,  or  malignant — and 
in  hsematuria  ;  in  cases  where  we  suspect  tuberculosis  or  gonorrhoea, 
and  to  clear  up  any  doubt  as  to  the  character  of  inveterate  dis- 
charges, a  bacteriological  examination  should  always  be  made.  All 
debris  removed  after  curettage  should  be  carefully  examined  and 
reported  upon,  and  the  report  preserved  for  future  reference. 

The  Ophthalmoscope  in  Diagnosis. — Did  space  permit  I  might 
enter  more  fully  than  I  am  now  enabled  to  do  into  the  subject  of 
ophthalmoscopic  examination,  in  the  diagnosis  of  uterine  affections, 
and  other  diseased  states  which  either  complicate  or  originate  the 
retinal  disorder.  It  is  not  too  much  to  say  that  every  educated 
physician  and  surgeon  should  at  least  know  suflicient  of  the  ophthal- 
moscope to  be  able  to  diagnose  an  albuminuric  retinitis,  a  hsemor- 
rhagic  infarction  due  to  temporary  retinal  congestion,  a  choked 
papilla,  the  retinitis  attendant  upon  diabetes,  the  striag  and  exuda- 
tion of  syphilis,  the  disseminated  choroiditis  of  the  same  disease, 
the  retinitis  of  pernicious  anaemia,  or  the  leuksemic  retina  of  ansemia 
and  leukaemia.     This  practical  acquaintance  with   the  use  of  the 


FIBST  STEPS  OF  EXAMIXATWX  OF  A    CASE.  99 

ophthalmoscope  is  of  still  greater  value  in  the  diagnosis  of  diseased 
conditions  both  during  and  after  pregnancy. 

It  is  well  known  how  frequently  some  retinal  extravasations  are 
the  result  of  secondary  cardiac  mischief,  which  has  its  source  in 
vascular  changes  due  to  morbid  states  of  the  blood — as,  for  instance, 
in  Bright's  disease  or  diabetes.  Most  important  are  such  ocular 
disturbances  in  pregnancy.  This  is  obvious  when  we  remember  the 
effects  produced  on  the  l)lood  by  pregnancy,  and  the  relative  impor- 
tance which  such  disturbances  bear  to  the  safety  of  the  patient — 
as  indications  of  head  complications  and  hajmorrhagic  discharges, 
either  before,  during,  or  after  labour. 

The  Ophthalmoscope  in  Threatening  Eclampsia. — L.  de  Wecker 
cites  the  following  case  : —  * 

'  A  yoimg  American  lady,  twenty  years  of  age,  who  was  in  her  seventh 
month  of  pregnancy,  complained  that  her  sight  had  been  somewhat  dim 
during  the  last  few  days.  Her  husband  begged  me  to  examine  her  that 
very  evening,  although  to  do  this  I  had  to  disturb  a  large  dinner-partj-, 
which  neither  the  conditio q  of  her  sight  nor  health  prevented  her  taking 
part  in,  I  found  that  there  was  a  very  slight  haziness  of  the  retina  in 
the  neighbourhood  of  the  papilla  in  both  eyes,  and  deferred  fiuther  ex- 
amination tUl  the  next  daj'.  At  ten  o'clock  the  following  morning  the 
ophthalmoscope  showed  on  the  left,  near  the  papilla,  a  small  extravasa- 
tion, which  certainly  could  not  have  escaped  my  investigation  of  the  previous 
evening.  Meeting  a  colleague,  in  consultation,  I  informed  him  of  the  fresh 
haemorrhage  in  the  left  eye  and  the  increased  haziness  of  the  papiUa,  and 
begged  him  to  allow  premature  labour  to  be  brought  on.  I  felt  convinced 
that  it  would  not  be  long  before  serious  brain  symptoms  would  declare  them- 
selves, and  that  in  any  case  this  primipara  would  not  arrive  at  her  full  time 
without  some  accident.  One  of  the  most  celebrated  accoucheurs  in  Paris 
was  called  in  further  consultation,  but  I  was  unable  to  convince  him  of  the 
danger.  During  the  night  which  followed  this  consultation — that  is  to  say, 
four  days  after  the  first  ophthalmic  examination — the  patient  was  seized 
with  convulsions,  following  each  other  in  rapid  succession.  In  aU  haste  Dr. 
Campbell  was  sent  for,  but  he  did  not  feel  justified  in  forcibiy  delivering  a 
patient  who  lay  unconscious  and  in  a  moribund  condition.  Death  occurred 
the  following  night.' 

There  can  be  little  doubt  that  at  least  10  per  cent,  of  cases  of 
Bright's  disease  suffer  from  retinal  complications.  This  is  placing 
the  number  at  a  low  figure. 

A  primipara,  aged  26,  in  the  fifth  month  of  pregnancy,  consulted  me  for 
ocular  symptoms — twitching  of  the  eyelids,  dimness  of  vision,  some  pain 

*  '  Ocular  Therapeutics,'  trans,  by  Litton  Forbes. 


100 


DISEASES   OF   W03IEX. 


and  frontal  ache.  There  was  some  50  per  cent,  of  albumen  in  the  urine. 
The  papillaj  were  hypersemic,  and  there  was  a  surrounding  haziness.  Labour 
was  iucluced  the  following  day  at  3.30  p.m.,  convulsions  beginning  at  11  p.m. 
The  uterus  was  emptied  at  1  p.m.,  an  adherent  placenta  giving  some  trouble. 
The  patient  was  kept  under  chloroform  from  11  p.m.  until  2.30  the  following 
day,  convulsions  recurring  on  any  ^vithdrawal  of  the  anjesthetic.  A  sub- 
cutaneous injection  of  one-tenth  of  a  grain  of  nitrate  of  pilocarpine  was  then 
administered,  producing  rapidly  its  full  physiological  effects,  after  which  the 
convulsions  ceased,  and  the  patient  made  an  excellent  recovery. 


Fig.  77. — Central  Choroido-eetinitis.    Appearance  op  the  Left  Fundus 

FOLLOWING   UPON   PAETUraTION   AND    SeVEEE  PoST-PAPvTUJI   HEMORRHAGE. 

The  papilla  is  partially  atrophied.  The  group  of  white  dots  is  seen  in  the 
region  of  the  macula.  Here  also  were  some  remains  of  hsemorrhagic 
infarctions.  The  group  of  dots  was  quite  distinct  from  urtemic  patches. 
It  corresponds  with  the  retinitis  guttata  of  Nettleship.  This  patient  died 
four  years  subsequently  of  ursemic  and  other  complications  (p.  103). 


Were  the  use  and  knowledge  of  ophthalmoscopy  generally  insisted  on, 
many  diseases  would  be  more  frequently  recognized  in  their  earlier  stages, 
and  a  timely  warning  given.  In  noticing  L.  de  Wecker's  allusion  to  the 
contra-indication  of  hot  baths  in  retinal  lesions  dependent  upon  nephritis, 
I  am  reminded  of  three  cases  of  sudden  death  occurring  within  my  own 


FIRST  STEPS   OF  EXAMINATIOX   OF  A    CASE. 


nil 


experience  which  were  caused  in  this  manner.  One  instance  was  that  of 
a  lady  who  noticed  that  her  vision  was  affected  for  a  few  days,  and  called 
on  me  to  have  an  examination  made.  I  happened  to  be  absent.  She  left 
word  that  she  would  come  the  next  day.  That  night  she  took  a  hot  bath, 
which  she  had  fre-piently  taken  before,  was  attacked  while  in  the  bath,  and 
died  in  a  few  hours  of  apoplexy.  An  ophthalmoscopic  examination  that  day 
might  have  saved  her  life. 


Fig.  78. — H^tmokrhagic  Ixfaectioxs  followixg  on  ALBrjiiyuEic  Ketdsitis 

DCBIXG   PbEGXAXCY. 

V  restored  both  eyes  to  f. 

A  patient  from  whom  I  removed  the  adnexa  with  a  parovorian  cyst,  sub- 
sequently conceived,  and  suffered  during  her  pregnancy  from  albuminuric 
retinitis.  Sudden  haemorrhage  occurred  into  the  retin8e  of  both  eyes.  From 
this  she  became  practically  blind.  The  extravasation,  however,  gradually 
disappeared  after  her  delivery  at  full  term.  The  drawing  was  taken  during 
the  time  of  convalescence  (Fig.  78). 

I  could  multiply  instances  in  which  both  the  detection  and  diagnosis  of 
existing  disease  have  been  due  to  the  ophthalmoscope.  '  The  retinitis  of 
malignant  ansemia  is  so  constant,'  says  L.  de  Wecker,  '  that  it  may  be  looked 
on  as  pathognomonic' 


102 


DISEASES   OF   WOMEN. 


/     I 


£4 


Fig.  79. — Choked  Optic  Papilla  of  a  Patient,  occderinTt  during 
Suppression  of  the  Catamenia. 


!1_ 


Fig.  80. — Same  Papilla  ^vhen  kecoylring. 

Treatment  locally,  instillation  of  pilocarpine  and  eserine  (physostigmine) ; 
and  internally,  ergot  and  iodide  of  potassium. 


FIRST  STEPS   OF  EIAMIXATION   OF  A    CASE.  103 

The  patient  from  whom  the  drawing  (Fig.  77)  was  taken  never  had  had 
any  affection  of  the  eye  before  parturition.  Three  days  after  her  labour  very 
severe  post-partum  hjemonliage  occurred,  and  she  found  the  v\s\Qn  of  the  right 
eye  defective.  She  was  sent  to  me  by  Dr.  Wm.  Slimon  six  weeks  after  labour. 
The  vision  then  was  reduced  to  the  counting  of  fingers  at  a  distance  of  5  feet. 
The  entire  region  of  the  macula  was  dotted  over  with  white  dots.  It  pre- 
sented much  the  look  of  a  retina  suflfering  from  Tay's  '  choroiditis  guttata ' 
(centralis),  or  the  spots  of  '  disseminated  choroiditis '  which  has  been  described 
by  various  authors. 

In  this  case  there  had  been  no  albuminuria  during  pregnancy.  The  vision 
was  suddenly  affected,  and  the  appearances  are  quite  distinct  from  those 
seen  in  the  retinitis  albuminuria  of  pregnancy  and  Bright 's  disease.  It  would 
appear  that  there  was  after  the  labour  some  infarction  of  the  retinal  vessels 
following  on  the  severe  uterine  haemorrhage,  and  that  possibly  a  state  of 
thrombosis  was  induced.  This  set  up  an  irritation  in  the  region  of  the 
macula,  which  was  followed  by  the  peculiar  exudation.  The  exact  nature  of 
these  dots  is  not  understood.     Hutchinson  believes  them  to  be  colloidal. 

I  have  known  women  whose  symptoms  were  asci'ibed  to  amenor- 
rhoea,  hysteria,  anaemia,  a  disorder  of  pregnancy,  a  dyspeptic  state, 
gastric  distui'bance,  or  liver  derangement,  in  whom  an  ophthalmo- 
scopic examination  and  the  discovery  of  optic  neuritis,  choked  disc, 
detached  i-etina,  retinal  apoplexy,  pulsating  vessels,  Bright's 
degeneration,  or  syphilitic  effusion,  would  have  afforded  a  clue  to  a 
correct  diagnosis. 

Consequences  of  Eye-strain  in  "Women. — I  would  here  draw 
attention  to  a  most  important  complication  which  will  be  found  in 
a  certain  proportion  of  patients  who  consult  us  for  female  disorders. 
I  refer  to  eye-strain,  with  all  its  consequences  on  the  nervous  system. 
This  eye-strain,  due  to  errors  of  refraction,  is  often  followed  by  such 
symptoms  as  headache,  difficulty  of  thought  concentration,  nausea, 
and  neuralgia.  Even  epileptic  seizures  have  been  proved  to  have 
their  origin  in  an  uncorrected  astigmatism.  These  effects  are 
especially  accentuated  in  many  women  prior  to,  and  during,  men- 
struation. Xaturally,  they  are  more  felt  in  the  instance  of  a 
neurasthenic  woman  who  is  suffering  from  the  dual  trouble  of  the 
refractive  error  and  some  menstrual  aberration.  Hence  we  find 
them  frequently  present  at  puberty,  during  pregnancy,  and  in  the 
climacteric.  This  association  is  specially  worthy  of  the  attention  of 
the  gynaecologist,  as  not  infrequently  disorders  of  the  pelvic  viscera 
are  present. 

In  the  chapters  on  '  Uterine  Xeuroses '  sufficient  evidence  will  be 
found  of  the  concurrent  occurrence  of  aberration  of  function  in  the 
generative  organs  with  disturbance  of  the  brain  or  cranial  nerves. 


104  DISEASES   OF   WOMEN. 

At  the  annual  meeting  of  the  British  Medical  Association,  1895,  I  read  a 
paper  in  the  Ophthalmological  Section  on  this  subject,  pointing  out  that  in 
the  unstable  state  of  nervous  excitability  or  irritability,  to  which  women 
suffering  from  pelvic  disease  are  liable,  there  is  a  predisposition  to  central 
effects  of  possibly  slight  peripheral  ailments.  I  then  gave  the  particulars  of 
fifty  cases  of  women  of  various  ages  who  consulted  me  within  a  compara- 
tively short  time,  most  of  Avhora  suffered  from  some  form  of  pelvic  disorder, 
and  in  whom  the  symptoms  above  referred  to  were  present.  Not  one  of 
these  patients  attributed  any  of  tJie  symptoms  to  a  visual  defect,  yet  in  all 
there  were  varying  degrees  of  astigmatism,  in  the  gi'eat  majority  relief  from 
the  head  symptoms  following  on  the  correction  of  the  refraction  by  suitable 
lenses. 


Headache  the  result  of  Eye-strain. 

A  few  cases  are  sufficient  to  illustrate  the  point  I  desire  to 
emphasize — viz.  that  in.  women  who  suffer  from  such  symptoms  as 
headache,  nausea,  mental  fatigue,  and  difficulty  in  concentration  of 
thought,  errors  of  refraction  should  be  sought  for  as  part  of  the 
general  treatment  of  the  case  : — 

A  young  lady,  aged  twenty-two,  a  proficient  musician,  suffered  from 
various  local  and  other  symj^toms,  Avhich,  upon  examination,  were  found  to 
be  due  to  retroversion  of  the  uterus.  Attendant  upon  these  was  constant 
and  severe  headache.  This,  it  was  hoped,  would  disappear  with  the  rectifica- 
tion of  the  displacement.  She  was  advised  to  consult  me  as  to  the  need  for 
continuing  to  wear  the  support.  This  she  did,  complaining  at  the  same  time 
of  the  continuance  of  very  bad  headaches,  though  she  had  recovered  from 
her  other  local  troiibles.  On  examining  the  eyes,  I  found  that  she  had 
myopic  astigmatism,  which  had  never  been  corrected,  as  she  was  wearing 
simple  spherical  glasses  for  all  work.  With  -lo  cyl.  added  to  her  spherical 
lenses,  this  was  completely  con-ected,  and  when  last  I  saw  her,  her  headaches 
had  ceased. 

Mrs. ,  aged  forty-six,  had  suffered  from  severe  headaches  on  and  off" 

for  years.  She  was  now  in  the  menopause,  with  irregular  catamenia.  Her 
headaches  had  of  late  become  much  worse.  Further  than  an  enlai'ged 
uterus,  with  some  tenderness,  there  was  no  pelvic  trouble.  She  had  never 
suspected  her  eyes  as  a  cause  of  her  headaches.  Several  teeth  were  carious  ; 
these  were  removed.  On  examination,  I  found  hj^Deropic  astigmatism,  which 
was  completely  corrected.  When  I  last  heard  of  her,  about  one  month  after 
wearing  the  glasses,  her  headaches  had  completely  disappeared. 

Mrs.  H ,  aged  fortj^,   consulted  me  for  general  ill-health,  including 

metron-hagia  and  other  pelvic  symptoms.  She  had  as  violent  head  pain  as 
I  have  ever  known  of.  All  the  teeth  in  the  upper  jaw,  being  carious,  had 
been  extracted  for  this  latter  symptom,  without  affording  relief  She  had  a 
uterine  cervical  erosion  and  endometritis.  She  was  cured  of  these  latter 
troubles,  but  the  head  symptoms  continued.     On  examination  of  the  eyes,  I 


Fin  ST  STEPS   OF  EXAMINATION  OF  A    CASE. 


105 


found  myopic  astigmatism  of  the  right,  and  hyperopic  of  the  left  eye :  -2*5 
cyl.  (vertical)  in  the  right  eye,  +  U-25  spher.  and  +  0"25  cyl.  (horizontal) 
in  the  left  eye,  brought  her  to  nearly  Jf.  She  has  been  completely  relieved. 
Careful  attention  in  all  cases  was  paid  to  any  attendant  asthenopia,  and  any 
errors  of  insufficiency  were  corrected  by  prisms. 

Exploratory  Incision. — Having  exhausted  all  our  means  of  diag- 
nosis, and  doubt  still  remaining,  in  a  case  of  abdominal  tumour, 
where  the  question  of  operation  arises,  there  is  yet  abdominal 
exploration.  This  step  is  not  to  be  resorted  to  save  as  a  dernier 
ressort,  as  in  itself  it  is  not  devoid  of  danger.  E\'ery  antiseptic 
precaution  is  taken  before  and  during  the  exploration.  A  small 
incision  is  made  through  the  skin  over  the  linea  alba.  The  knife 
is  carried  on  carefully  through  the  cellular  tissue,  fat,  tendinous 
structures,  and  subperitoneal  tissue.  All  bleeding  is  arrested  by 
torsion  or  ligature.  The  peritoneum  is  now  examined.  The  shining 
wall  of  an  ovarian  cyst  may  be  seen  lying  underneath.  The  peri- 
toneum is  next  carefully  raised  by  a  tenaculum,  or  caught  up  in 
a  fine  forceps,  and  a  small  opening  made  which  is  enlarged  on  a 
director  for  the  extent  of  an  inch  and  a  half  to  two  inches.  We 
are  thus,  with  two  fingers,  enabled  to  examine  an  adjacent  cyst-wall, 
search  for  adhesions,  or  explore  the  abdominal  cavity. 

Examination   of  the   Rectum. — When  the  rectum  has  to    be 


«« 


Fig.  81. — Rtall's  Expanding  Rectal  Speculum. 
examined  for  fistula?,  fissures,  ulcers  or  htemorrhoids,  we  may  require 


106 


DISEASES   OF    WOMEN. 


a  speculum  (Figs.  81,  83).  As  a  rule,  the  educated  finger  of  the 
surgeon  who  is  familiar  with  the  feeling  conveyed  by  the  margins 
and  roughness  of  an  ulcer,  the  internal  aperture  of  a  fistula,  the 
ridge  and  sharp  sulcus  of  a  fissure,  the  contraction  of  a  stricture, 
the  hardness  and  irregular  surface,  often  easily  bleeding,  of 
malignant  disease,  gives  the  most  reliable  and  certain  information. 
The  patient  is  placed  on  the  couch,  the  nates  are  drawn  well  to  the 
edge,  and  the  thighs  flexed. 

I  seldom  use  any  rectal  speculum.  I  show  three  which  are  in 
common  use — those  of  Ryall,  Gowland,  and  Davy.  Ryall's  rectal 
speculum  is  an  ingenious  instrument.  I  refer  to  it  in  the  chapter 
on  the  'Rectum.' 

Proctoscopy. — Kelly  practises  proctoscopy  by  means  of  the  proctoscope 
— a  rectal  speculum  protected  by  an  obturator.  The  light  from  an  electric 
lamp  is  cast  into  this  from  a  forehead  mirror.     The  buttocks  of  the  patient, 


Fig.  83. — Rectal  Speculum.     (Gowland's.) 

who  is  in  the  knee-elbow  posture,  are  placed  against  uprights,  to  which  the 
thighs  are  fixed,  and  thus  the  surface  of  the  mucous  membrane  is  inspected. 
(See  chapter  on  '  Rectum '  for  the  illustration  of  Howard  Kelly's  method.) 

Examination  of  the  Urethra.* 

To  explore  the  urethra,  I  employ  my  dilators  (Fig.  68).  Gradual 
dilatation  can  be  finally  completed  with  the  finger.  If  nothing  else 
be  at  hand,  a  small  glove-stretcher  may  be  used.     Howard  Kelly's 


Fig.  84. — A^ulcanite  and  Glass  Syeinge  foe  Uterine  and  Bladder 

Injections. 

method  of  examination  of  the  bladder  and  ureters  (as  also  Kolliker's), 
by  the  cystoscope,  are  described  in  the  chapters  on  the  '  Bladder 
and  Ureters.' 

*  See  chapter,  '  Anatomical  and  Clinical.' 


CHAPTER  IV. 

ASEPSIS   AND   ANTISEPSIS   IN   GYNAECOLOGICAL 

SURGERY. 

With  regard  to  hospital  methods  for  securing  asepsis,  there  can  be 
no  possible  excuse  for  even  the  slightest  defect  in  any  of  the  details 
of  aseptic  surgery.  Here  economy  has  seldom  to  be  considered.  In 
his  theatre,  appliances  and  assistance,  both  before,  dui'ing,  and  after 
operations,  the  surgeon  is  amply  provided  for  ;  and  it  is  simply 
unpardonable  if  any  accident  occurs  which  can  by  possibility  be 
traced  to  a  flaw  in  the  methods. 

It  is,  therefore,  rather  with  a  view  to  insisting  on  the  need  for 
caution  outside  the  hospital  operating  theatre  and  ward  that  I  write 
this  short  summary  of  the  methods  that  I  myself  pursue.  I  have 
not  the  least  doubt  that  there  is  still,  even  with  all  our  knowledge 
of  the  vital  importance  of  asepsis,  a  great  deal  of  inexcusable  negli- 
gence in  the  manner  in  which  this  first  essential  of  the  modern 
surgical  art  is  achieved ;  in  short,  there  is  much  that  is  casual  in 
the  manner  in  which  prepai"ations  are  made,  and  the  regard  that  is 
placed  on  such  precautions.  Possibly  this  may  arise  from  the  fact 
that  though  in  a  misty  sort  of  way  the  need  for  them  is  recognized, 
it  has  only  been  of  recent  years  that  the  profession  generally  has 
begun  to  realize  their  vital  necessity.  This  observation  applies  to 
surgeon  and  nurse  alike.  Looseness  in  the  education  of  both  has 
generated  a  corresponding  laxity  in  their  ideas  as  to  how  complete 
asepsis  is  to  be  maintained  ;  and  we  are  now  in  that  transition  stage 
between  the  older  practices  of  simple  antisepsis,  often  indifferently 
carried  out,  and  the  far  more  scientific  and  correspondingly  difficult 
aseptic  procedures  of  the  present  day.  Those  educated  under  the 
old  plan  find  it  difficult  to  adapt  their  surgery  to  the  demands  of  the 
latter,  nor  in  some  respects  can  we  blame  them,  when  we  still  find 
responsible  teachers  and  operators  who  speak  slightingly  of  the 
unnecessary  refinement  of  care  with  which  the  majority  of  modern 
surgeons  strive  at  asepsis. 


108  DISEASES   OF   WOMEN. 

Convinced  of  the  extreme  importance  of  exact  attention  to  the 
minute  details  as  well  as  to  the  general  pi-inciples  of  asepsis  and 
antisepsis,  my  object  is  to  lay  down  precise  rules,  based  on  my  own 
experience  and  that  of  others,  to  be  observed  in  the  arrangements  of 
the  operating-room,  the  preparation  of  the  patient,  the  operator,  and 
his  assistants,  and  the  care  of  instruments,  dressings,  and  other 
appliances,  dealing  with  the  matter  more  especially  from  the  point 
of  view  of  the  abdominal  surgeon  and  gynaecologist.  And  in  order 
to  make  these  observations  as  practical  and  useful  as  possible,  I 
shall  enter  into  the  question  of  the  installation  of  a  private 
operating-room  with  everything  that  is  essential  to  the  purpose. 

I  am  in  perfect  agreement  with  the  views  of  Doyen  ■"'  that- 
'when  we  lose  a  patient  who  has  been  operated  upon,  the  most 
common  cause  of  death  is  infection  within  the  operative  tract.'  an 
infection  facilitated  by  the  reduction  of  the  vital  resistance  brought 
about  in  enfeebled  and  in  cachectic  subjects,  particularly  among 
the  cancerous.  A  pretension  to  infallibility  in  asepsis  is  as- 
ridiculous  as  it  is  dangerous.  Even  in  cases  where  complications 
occur  at  a  distance  from  the  field  of  operation,  such  as  bron- 
chitis, pneumonia,  phlebitis,  etc.,  it  is  rarely  found  that  they  arise 
from  any  cause  save  as  the  direct  consequence  of  interference. 
'  If  the  patient  should  succumb,'  says  Doyen,  '  carefully  study  the 
probable  causes  of  death,  and  question  your  memory  on  the  minutest 
details,'  and  he  goes  on  to  remark  that  to  an  interference,  out  of  all 
proportion  to  the  vital  resistance  of  the  patient,  which  has  been  too- 
prolonged,  or  to  infection  alone,  we  may  often  ascribe  the  fatal  issue, 
and  still  more  frequently  to  both  causes  combined.  This  conclusion 
he  says  he  has  come  to  as  the  result  of  many  years  of  experience,, 
acquired  in  the  service  of  various  hospitals  in  which  bacteriological 
observations  of  the  most  searching  kind  were  conducted  as  to  the 
causes  of  death  after  operations. 

This  fact  has  always  to  be  remembered  by  those  who  profess  to 
ignore  strict  asepsis  in  their  operations — that  no  matter  how  brilliant 
their  results  may  be,  if  they  have  lost  a  single  case  through  neglect 
of  aseptic  and  antiseptic  precautions,  they  have  dearly  paid  for  their 
antagonism  to  the  almost  universal  practice  of  the  day. 

Some  may  consider  that  certain  details  are  carried  to  extremes  in 
the  Continental  and  American  Minihs.  I  do  not  think  so.  There 
may  be  limits  to  our  possibilities  in  private  '  homes  '  and  houses,  but 

*  Doyen's  '  Technique  Chirurgicale  '  (Paris  :  Masson  and  Co.,  120,  Boulevard 
St.  Germain). 


ASEPSIS  AND  ANTISEPSIS  IN  GYNJECOLOGICAL   SURGERY.     109 


there  are  no  such  limiting  conditions  in  our  hospitals.  Far  better 
this  attention  to  the  minutest  details,  than  that  the  entire  system 
should  be  rendered  ridiculous  by  glaring  oversights  on  the  part  of 
operator,  assistants,  and  nurses,  in  the  handling  and  transferring  of 
instruments,  ligatures,  and  sutures,  in  the  casual  exposure  of  these 
to  sources  of  infection  before  and  during  operative  manipulations, 
and  by  other  faults  of  omission  and  commission.  Such  errors  justly 
brought  severe  criticism  on  our  British  antiseptic  methods — criticism 
which  cannot  l)e  answered.  This  should  not  be  so  in  the  birth-place 
of  antiseptic  surgery.  Call  it  by  whatever  name  we  may,  the 
surgical  world,  in  the  twentieth  century,  with  such  few  excep- 
tions that  they  seem  only  to  prove  the  rule,  has  accepted  the 
teachings  of  Lister,  and  the  universality  of  that  acceptance,  as 
well  as  the  results  of  the  adoption  of  those  teachings,  are  unanswer- 
able testimonies  to  their  truth.  No  theory  in  the  histoiy  of 
medicine  has  been  subjected  to  more  universal,  more  crucial  tests, 
by  observation  or  experiment,  than  that  of  the  germ  theory  in 
wounds,  in  relation  to  septic  changes  in  these.  The  practical  result 
has  been  the  universal  adoption  of  aseptic  surgery,  and  no  depart- 
ment of  the  surgical  art  has  benefited  more  by  the  use  of  antiseptic 
and  aseptic  methods  than  that  of  gynaecology. 

The  directions  here  given  for  the  conduct  of  aseptic  preparations,  and  the 
completion  of  a  thoroughly  aseptic  operation,  are  written  after  visits  to  the 
Frauen-Kliniks  of  Martin,  Olshausen,  and  the  Landaus  in  Berlin  ;  of  Schauta 
in  Vienna ;  the  cUniques  of  Terrier  and  Hartmann  at  the  Eopital  Bichat 
and  that  of  the  installation  of  Doyen  in  Paris;  Sanger  and  Kleinhans  in 
Prague;  "Winckel  and  Gustav  Klein  in  Munich;  Paul  Zweifel,  and  Kronig 
and  Menge  in  Leipzig ;  Leopold  in  Dresden ;  Bumm  m  Halle. 

'Asepsis'  and  'Antisepsis.' — The  differentiation  of  the  terms 
'  antisepsis '  and  '  asepsis '  is  hardly  understood.  The  need  for 
separating  into  two  distinct  categories  septic  and  aseptic  operations 
is  not  fully  appreciated  or  realized,  either  by  surgeons  or  nurses. 
Antisepsis  before,  and  asepsis  during,  an  operation,  should  be 
secured  by  methodical  and  systematic  precautions  never  departed 
from.     This  is  an  invariable  rule. 

It  is  no  infrequent  occurrence  for  a  nurse  to  constantly  assure  the 
surgeon  that  she  is  thoroughly  versed  in  both  antiseptic  and  aseptic 
methods,  and  yet  to  find  that  when  she  is  subjected  to  the  practical 
test  of  attendance  upon  an  operation  and  attention  to  a  case,  she 
is  deficient  in  many  of  the  first  principles  of  her  work.  There  can 
be  only  one  standard  for  the  hospital  surgeon  on  the  one  hand,  and 


110  DISEASES  OF   WOMEN. 

the  practitioner  or  surgeon  who  operates  in  the  private  '  home ' 
or  house  on  the  other ;  and  though  the  latter  may  not  be  able 
to  achieve  that  degree  of  perfection  which  should  always  be  at  the 
command  of  the  former,  still  he  must  strive,  so  far  as  it  is  within  his 
means  and  possibilities,  to  do  so.  Fortunately,  in  consequence  of 
all  the  recently  constructed  appliances  which  render  it  easy  for  the 
surgeon  to  carry  with  him,  without  danger  of  contamination  from 
any  outside  source,  all  his  sterilized  instruments,  dressings,  com- 
presses, and  sponges,  as  well  as  his  various  ligatures — and  not  only 
these,  but  also  the  sterilized  nail-brushes,  antiseptic  soap,  and  the 
overalls  for  himself  and  assistants — ^the  operator  can  reduce  his  risk 
of  failure  in  detail  to  a  minimum.  And  there  is  no  longer  any  ex- 
cuse that  can  be  advanced,  either  on  the  part  of  those  who  have  to 
prepare  for  an  operation  or  of  the  operator,  for  subjecting  the  person 
whose  life  he  is  taking  in  his  hands  to  an  unnecessary  risk,  for  the 
incurring  of  which  there  can  be  but  two  explanations — ignorance  or 
negligence. 

It  may  not,  then,  be  without  advantage  to  emphasize  what  true 
antisepsis  and  asepsis  really  mean.  By  asepsis  I  understand  an 
absence  of  all  septic  organisms.  This  condition  is  secured  by 
certain  methods  which  have  relation  to  the  sterilization  of  the  hands 
of  the  operator,  assistants,  and  nurses  ;  of  the  area  of  operation 
before,  during,  and  after  surgical  intervention ;  and  the  instruments, 
sutures,  sponges,  dressings,  and  other  appliances  employed.  When 
no  pathogenic  organisms  are  present,  the  condition  is  one  of  asepsis. 

By  antisepsis  I  understand  any  or  all  of  the  methods  by  which 
such  absence  of  septic  germs  is  obtained.  These  methods  will 
therefore  include  disinfection  by  hot  air,  steam,  boiling  water,  and 
the  use  of  the  various  chemical  germicides  that  destroy  or  render 
inactive  the  pathogenic  organisms. 

For  many  years  a  condition  of  -perfect  asepsis  in  operations  has 
been  the  ideal  of  surgeons.  It  is  hardly  too  much  to  say  that  even 
at  the  present  day  the  best  results  obtained  are  only  an  approxi- 
mation in  the  direction  of  that  ideal.  But  of  this  we  may  rest 
assured,  that  the  nearer  we  come  to  its  realization,  the  nearer,  also, 
we  shall  attain  to  the  elimination  of  all  preventable  morbidity  and 
mortality  after  operations. 

A  fundamental  difficulty  in  the  securing  of  perfect  asepsis  lies  in  the  fact 
that  various  organisms,  some  of  them  pathogenic,  are  constantly  present  in 
the  skin,  in  the  digestive  canal,  and  in  the  female  genital  passages  up  to  the 
OS  uteri  internum ;  of  those  inhabiting  the  skin,  at  least  one  organism,  the 


a  -s 


o  .2 


g     ^    o 


—     o  ■*= 
fcC  § 


{To  face  p.  110. 


-<      S 


o 


[To/acei3.  HI- 


ASEPSIS  AND  ANTISEPSIS  IX  GYNA'X'OLOO [CAL    SURGEHV.     HI 


Staphylococcus  pyogenes  alhus  (Staphylococcus  epidermis  alhus,  Welch),  lies 
deeply  in  the  epidermis,  or  hair  follicles,  beyond  tlie  reach  of  any  antiseptics. 
On  the  other  hand,  it  is  to  be  remembered  that  infection  depends  not  only  on 
the  presence  of  a  germ,  but  also  on  the  weakening  of  the  resistance  of  the 
tissues ;  conseqiientlj',  wth  favourable  circumstances,  an  organism,  otherwise 
pathogenic,  may  be  in  fact  inert,  so  that,  as  Howard  Kelly  truly  says,  'a 
fresh  wound  containing  these  organisms  may,  from  a  surgical  standpoint,  be 
considered  as  aseptic  when  the  process  of  healing  is  in  no  way  interfered  with.' 

The  Operating-room, — My  object  being,  as  I  have  said,  to  dwell 
rather  on  the  necessity  that  exists  outside  a  public  hospital  for  the 
adoption  of  as  complete  asepsis  and  antisepsis  as  may  be  secured, 
I  desire  to  show  how  a  small  private  operating-room  can  be  con- 
structed at  a  comparatively  small  cost,  and,  though  not  as  perfect 
as  the  theatre  of  a  hospital,  can  still,  so  far  as  the  materials  for 
asepsis  and  antisepsis  are  concerned,  be  brought  as  near  to 
perfection  as  can  be  hoped  for  with  the  means  at  our  disposal. 

The  room  selected  must  be  well  lighted  and  well  ventilated.  The 
best  window  is  a  sloping  skylight  facing  the  north.  The  floor  may 
be  composed  of  square  encaustic  tiles,  or  of  a  well-laid  parquet 
flooring  thoroughly  saturated  with  wax,  and  highly  polished.  A 
more  economical  plan  is  to  have  the  floor  cemented  ;  or,  as  a  still 
cheaper  expedient,  a  highly  glazed  through  and  through  linoleum 
may  be  used.  The  skirting  of  the  floor  all  round  the  linoleum  must 
be  kept  dust  free  by  a  triangular  piece  of  teek  fitting  accurately  to 
the  wall.  In  any  case,  the  floor  should  be  well  washed  daily,  and 
scrubbed  once  or  twice  a  week.  On  the  walls  and  ceilings  there 
should  be  no  ornamentation  or  projections  ;  and  it  is  an  advantage 
to  have  all  angles  rounded  off".  The  material  of  the  walls  should  be 
a  hard  smooth  cement,  coated  with  some  kind  of  enamel.*  All 
walls  and  shelves  should  be  prepared  with  this. 

For  artificial  illumination  electric  light  answers  best.  Where 
there  is  no  electric  installation  the  incandescent  gas-burner  can  be 
availed  of.  One  good  light  should  be  placed  just  above  the 
operating-table,  as  shown  in  the  place.  It  should  be  of  50-candle 
power,  and  contained  in  a  reflector.  The  one  in  my  theatre  is  thus 
intensified  so  as  to  give  a  light  of  1 50-candle  power.  This  light 
should  be  suspended  by  weight  and  pulley,  and  worked  on  a 
universal  crank  so  as  to  turn  at  any  angle.  A  second  bull's-eye 
light  on  a  lever  stand,  to  be  raised  or  lowered  at  pleasure,  and  to 

*  For  this  purpose  a  beautiful  '  lacquered  paint '  is  made  by  Messrs.  Flico- 
teaux,  83,  Kue  de  Bac.  Paris,  which  gives  a  ijoiceluin  surface,  is  capable  of 
being  scratched  without  detriment,  and  is  thorouglily  aseptic. 


112 


DISEASES    OF   WOMEN. 


work  at  any  angle  (see  Fig,  86)  ca2i  be  connected  by  a  plug  and 
cord  with  any  Acting. 

Hot  and  cold  water  should  be  laid  on ;  porcelain  sinks  are  the 
best,  and  the  taps  should  be  turned,  and  the  waste  plug  lifted,  by 
pedal  arrangement.  In  addition,  one  or  two  portable  lavabos 
are  required  for  rinsing  and  disinfecting  the  hands  during  an 
operation. 

Plenty  of  sterilized  water  should  always  be  available.     Without 
special  apparatus   this  can  only  be  obtained  by  boiling  water  for 
half  an  hour  and   allowing  it  to 
stand    in    covered    vessels    for    a 
longer  or  shorter   time  according 
to  the  temperature  required.     A 


:[)©»«=. 


Fig.  85. — Electric  Lasip  with  Re- 
FLECTOii  (150  Candle). 

Can  be  adjusted  to  any  angle.  It  is 
suspended  by  a  pulley  over  the  ope- 
rating table. 


Fig.  86. — Standard  Lamp  avith 
Bull's-eye  Reflector  (50  Candle).. 

Can  be  quickly  raised  or  lowered  and 
adjusted  at  any  angle. 


''Geiser  "  is  useful  for  the  purpose  in  a  room  adjacent  to  the  theatre. 
Or  if  large  quantities  are  likely  to  be  used,  a  special  apparatus, 
such  as  a  copper  reservoir  lined  with  a  steam  coil  connected  with 
a  boiler,  is  required. 

Private  Installation. — 1.  I  may  here  describe  my  own  instal- 
lation at  the  "  home  "  in  which  I  operate.  The  room  was  thoroughly 
prepared  for  the  porcelain  paint  to  which  I  have  referred,  with 
which  it  and  the  doors  leading  to  it  were  entirely  covered.  All  the 
shelves  have  the  same  coating.  A  cupboard  off  the  room  is  used 
for  the  surgeon's  clothes,  overalls,  jackets,  aprons,  small  blankets 
for  the  patient,  and  various  bandages. 

Directly  over  the  table  is  suspended  an  electric  lamp  with 
reflector,  capable  of  throwing  a  150-candle  light  on  to  the  patient. 
This  is  readily  raised   or  lowered  by  pulley  action.     The  room  is 


ASEPSIS  AND  ANTISEPSIS  IN  (iYNJECOLOOICAL   SURGE RV.     113 

otherwise  lighted  by  electricity.  It  contains  the  vapour  and  dry 
sterilizers,  and  a  boiler,  used  for  the  supply  of  hot  water,  and  ;i 
Chamberland-Pasteur  filter.  In  it  are  also  the  movable  lavahos, 
which  can  be  readily  rolled  from  place  to  place.  One  contains 
sterilized  water  for  douching,  and  the  litre-marked  funnel  jar  for 


Fig.  87. — Movable  Lavabo  (Xo.  3). 

The  jars  contain  (1)  absolute  alcohol 
and  solution  of  perchloride  of  mer- 
cury equal  parts ;  (2)  lysoform  so- 
lution 1  per  cent. 


Flu.  88. — Lavabo  (So.  1),  fok 
Artificial  Servm,  axu  DorcHK. 


the  use  of  sterilized  serum,  should  such  be  required  in  emergency 
during  or  immediately  after  operation.  This  serum  is  made  by 
adding  7  parts  of  chloride  of  sodium  to  the  1000,  and  the  needle 
used  is  that  shown  in  Fig.  89.  This  is  introduced  into  the  sub- 
cutaneous tissue  under  the  mammary  gland,  and  about  a  litre  of  the 

I 


114  DISEASES   OE   WOMEN. 

fluid  is  allowed  to  flow  subcutaneously  in  cases  of  threatened 
collapse  from  haemorrhage  or  shock.  The  serum  should  be  sterilized 
at  130^,  and  injected  subcutaneously  in  a  dose  of  from  50  to  200 
grammes  as  often  as  twice  or  three  times  in  the  day,  or  even  more 
frequently  in  grave  cases. 

Two  glass  tables  hold  the  trays  for  the  instruments  used  in 
operating,  and  boxes  containing  the  various  sutures  and  ligatures. 
The  second  assistant,  standing  near  the  operator,  has  this  stand  at 
his  side.  He  hands  all  the  instruments  as  they  are  required,  as 
well  as  the  ligatures,  cut  straight  from  the  reels,  and  threads  the 
needles.  Another  small  lavabo,  placed  behind  and  to  the  side  of  the 
operator,  contains  lysoform  or  lysol  for  cleansing  the  hands  during 
operation. 


Fig.  89. — Xeedle  for  Artificial  Serum. 

I  am  in  the  habit  of  bmrning  a  formalin  lamp,  the  "  Alformant," 
in  the  room  for  several  hours  the  evening  before  operation,  and  the 
same  means  is  used  to  disinfect  the  closet  in  which  the  clothes  are 
kept.* 

Operations  performed  in  a  Private  House. 

From  what  I  have  said  I  think  it  is  manifest  that,  with  the 
facilities  we  now  possess  of  carrying  about  with  us  in  a  properly 
constructed  bag  everything  perfectly  sterilized  that  can  by  any 
possibility  be  required  for  an  operation,  if  we  have  an  intelligent 
assistant,  conversant  with  the  aseptic  methods,  we  can  fulfil  most 
of  the  conditions  that  are  demanded  of  us.  Clearing  a  room  of  all 
superfluous  furniture  and  draperies,  as  well  as  carjiets,  or  other 
sources  of  infection,  we  can  in  a  few  hours  have  all  the  woodwork 
thoroughly  scrubbed,  and  the  room  disinfected.  The  Alformant 
lamp  (Fig.  108)  enables  us  to  do  this,  without  injury  to  any 
surrounding  materials,  within  a  period  of  twelve  hours. 

Pei"haps  the  most  dangerous  element  in  an  operating-room  is  the 
uneducated  or  careless  nurse.     We  are  more  likely  to  have  to  face 

*  This  lamp,  -witli  the  tablets  for  burning  in  it,  can  be  had  of  the  Formalin 
Hygienic  Company.  For  air-sterilization,  1  tablet  in  1000  cubic  feet;  for 
disinfection,  10  tablets  in  1000  cubic  feet.  It  is  capable  of  dift'using  20  to  2.5 
tablets  of  dry  formalin  at  a  time. 


Convenient  table  for  ready  use. 


An  assistant  keeping  the  patient  in 
the  Trendelenburg  position. 
Fig.  90. — The  Trendelenburg  Position.     (Pozzi  axd  Jatle.) 


Fig.  91. —Adjustable  Frame  for  Trexdelexburg's  Positiox. 


This  table  I  use  for  all 
other  than  abdominal 
operations.  It  is  ad- 
justable to  a  height  of 
five  feet. 


Fig.  92. — Greig  Sjhth's  Table  of  Glass  axd  Nickel. 


116 


DISEASES    OF   WO  21  EX. 


this  risk  in  the  private  house  than  elsewhere.  It  is  always  better 
to  make  the  most  careful  selection  of  the  nurse  or  nurses  who 
directly  assist,  and  never  to  permit  any  nurse  who  prepares  the 
patient,  or  places  her  on  the  table,  to  assist  in  operation  unless 
there  has  been  the  most  rigorous  subsequent  disinfection  secured 
before  any  instruments  or  appliances  are  handled. 

In  any  private  house,  the  operating-room  should  be  as  far  as 
possible  removed  from  a  lavatory  or  housemaid's  closet,  and  the 
most  careful  disinfection  of  these  should  be  secured  if  they  are  near 
the  room  in  which  the  patient  sleeps  after  operation. 

Everything  needful  for  an  operation  should  be  ready  before  it 
commences,  and  there  should  be  no  necessity  for  any  one  to  leave 
the  apartment  while  it  is  proceeding.  In  any  private  house  there 
ought  to  be  in  readiness  for  the  surgeon — 


A  few  small  buckets  or  pails. 
Sufficient  basins. 
Disinfectant  solutions. 
Some    perchloride    of     mercury 

and  absolute  alcohol. 
A  supply  of  boiled  and  hot  water. 
Towels. 

Small  blankets. 
A  hypodermic  needle  with  tablets 

of  strychnine. 
Some  flannel  bandages. 
Irrigation-douche  with  tube  and 

nozzle. 


Two  rubber  sheets. 

A  suitable  table  which  has  been 
well  scrubbed  with  disinfec- 
tant. 

Small  table  for  anaesthetist's 
instruments. 

Small  tables  for  separate  basins 
for  the  rinsing  of  the  operator's 
and  assistants'  hands. 

Restoratives,  kept  together,  and 
apart,  for  use  in  emergency. 


Fig.  93. — Xickel  Box  fob  sterilizing  Needles. 

Sterilization  of  Appliances  and  Dressings. — In  any  aseptic 
operation  the  following  articles  should  be  ready  sterilized :  instru- 
ments, compresses,  dabs,  protectors  for  the  bowel,  gauze,  ligatures, 
sutures,  and  di^ainage-tubes,  with  sterilized  iodoform  gauze.* 

*  All  these  can  be  taken,  in  sterilized  boxes  (unopened)  or  wrapped  in 
sterilized  towels,  to  a  patient's  house. 


ASEPSIS  AXI)  ANTISEPSIS  JX  OrXJECOLOGICAL    SURGERY.     117 


There  are  a  few  simple  facts  with  regard  to  sterilization  which  have  to  be 
remembered.  Bacteria  do  not  survive  a  temperature  from  120"  to  iSC  C, 
and  the  spores  of  bacteria  are  destroyed  by  lower  temperatures  than  these 
when  they  are  submitted  to  air  which  is  saturated  with  the  vapour  of  water, 
while  at  even  lower  temperatures  still — say  100'  C. — micro-organisms 
succumb  if  the  temperature  be  maintained  for  a  sufficient  time,  and  repeated 
by  successive  sterilizations. 

The  dry  stove  I  employ  for  sterilizing  instruments  is  that  of 
Poupinel ; "'  it  is  a  small  model  of  that  used  by  Doyen.     It  contains 


Fig.  94. — Dry  Stove  for  Ixstrumiixts. 

air-tight  copper  or  nickel  boxes  for  the  instruments.  The  tem- 
perature in  this  stove  rises  from  150^  to  160",  and  the  sterilization 
lasts  for  one  hour.  I  use  Chamberland's  autoclave  (Fig.  96),  or 
vapour-stove,  for  the  sterilization  of  the  dressings,  compresses,  mops, 
dabs,  etc. J  In  this  stove  can  be  placed  two  air-tight  nickel  bottles 
or  boxes  containing  the  various  articles  to  be  sterilized.  Such  are 
portable,  and  can  be  carried  by  the  surgeon  in  going  any  distance 
to  an  operation.     The  dressings,  previously  moistened  with  water, 

*  Made  by  Lequeus  piaison  Wiesnegg,  64  Eue  Gay-lussac,  Paris). 

t  The  pads  used  instead  of  sponges  are  made  of  absorbent  wool  enclosed  in 
gauze.  Dabs  are  cut  in  squares  from  butter  muslin  ;  thicker  squares  of  the 
same  or  of  fine  toile  are  used  for  protecting  the  skin,  the  edges  of  the  wound, 
and  the  intestines. 


118 


DISEASES   OF    WOMEN. 


not  too  tightly  pressed  in  the  nickel  box,  are  subjected  to  a  tem- 
perature of  140°.  After  sterilization  they  are  moist,  to  which  there 
is  no  objection.  One  hundred  and  twenty  degrees  of  heat  is 
sufficient  for  the  sterilization  of  the  silk  ligatures,  as  a  greater 
degree  of  heat  is  apt  to  injure  them.  The  silk  may  be  rolled  on 
glass  or  nickel  reels,  wrapped  in  gauze,  and  placed,  moistened  with 
water,  in  a  nickel  bottle.     Such  silk  serves  only  for  one  operation. 


Fig.  95. — Nickel  Box  foe  placing  ix  the  Vapouk  StepvIlizee. 

Sterilization  of  Gut. — For  the  sterilization  of  catgut  *  the 
method  I  have  adopted  is  that  employed  by  A.  Martin's  Jclinik. 
The  catgut  is  laid  on  flat  glass  plates  and  placed  for  six  hours  in  a 
^-^L_  solution  of  corrosive  sublimate  (without  alcohol),  so  that  the 
catgut  is  well  covered  by  the  solution.  It  is  then  taken  out  and 
placed  for  twelve  hours  in  a  solution  composed  of  two  parts  of  the 
best  alcohol  and  one  part  of  oil  of  juniper.  It  is  then  transferred 
to  some  of  the  same  solution,  but  neioly  prepared,  and  kept  in  this 
till  required ;  but  it  must  so  remain  at  least  fourteen  days  before  it 
can  be  used.  Should  any  fatty  matter  appear  on  the  top,  it  must 
be  carefully  removed  with  a  spoon.  I  transfer  the  gut  to  absolute 
alcohol,  and  allow  it  to  remain  for  three  months  in  this  before  using 
it,  changing  the  alcohol  occasionally. 

Kronig  cumol  gut  I  have  now  used  in  a  very  large  number  of 
abdominal  operations.  It  has  answered  admirably.  The  process 
by  which  it  is  prepared  is  that  of  Professor  Ki'onig,  and  this  is 
carried  out  exactly  in  Dronke's  Fabrik  in  Cologne.  It  is  sterilized 
and  sent  out  in  hermetically  sealed  boxes  ready  for  use.f     Save  in 

*  Thoroughly  reliable  gut  of  every  size  may  be  bad  (with  full  instructions  for 
its  sterilization)  of  M.  Boebme,  54,  Orienburger  Str.,  Berlin.  Glass  reels,  and 
all  the  necessary  appliances  for  silk  and  gut  sterilization,  can  be  had  of  these 
makers.  This  gut,  which  is  that  used  by  A.  Martin,  can  be  had  of  different 
thicknesses.     It  is  very  strong  and  bears  any  needed  strain. 

t  Dronke's  Catgut  Handlung  Holu  a  Rh.  This  is  described  fully  in  the 
MUncliener  medicinischen  Wochenschrift,  No.  44,  1901. 


I 


ASEPSIS  AM)  AXTISEPSrS  AV  GYNECOLOGICAL   SCIiGEJil'.     110 

the  instance  of  the  very  large  thicknesses  of  gut,  which  may,  in  order 
to  soften  them,  be  first  dipped  in  sterilized  water  or  perchloride 
solution,  this  gut  is  used  direct  from  the  boxes.  It  can  be  had  in 
eight  sizes.  At  the  same  time,  save  for  the  convenience  of  obtain- 
ing it  ready  to  hand,  and  without  the  necessity  of  preparation,  I  do 
not  think  that  it  possesses  any  great  advantage  over  the  gut,  pre- 
pared by  Martin's  process,  that  I  have  been  using.  If  the  directions 
be  carefully  followed,  and  the  gut  itself  be  good,  I  can  guarantee 
it  to  give  complete  satisfaction. 


Chromicized  cumol  gut  is  prepared  by  KrrJnig  and  Zweifel  as  follows :  It 
is  lirst  wound  on  a  glass  plate  with  ground  edges,  so  as  not  to  cut  it.  It  is 
next  placed  in  chromic  solution  for  fifteen  minutes  (1  in  1000),  and  then 
washed  in  water.  It  is  a  second  time  placed  for  fifteen  minutes  in  the 
chromic  solution,  and  dried  at  a  temperature  of  80°  C.  It  is  then  made  into 
rolls  and  subjected  to  100°  C.  This  drying 
must  be  complete.  It  is  then  placed  in  cumol 
for  an  hour  and  a  half,  at  a  temperature  of 
160°  C.  It  is  now  put  into  benzine  of  petroleum 
with  a  sterilized  forceps,  and  the  benziu  is 
changed  after  half  an  hour.  It  is  finally  placed 
in  sterilized  glasses,  and  is  ready  for  use. 

Silk.*  —  The  following  is  the  method  ot 
sterilizing  sUk  employed  in  Johns  Hopkins 
Hospital,  and  it  is  that  pursued  by  me.  The 
skeins  of  silk  are  opened  and  cut  in  lengths 
of  40  centimetres  (16  inches)  for  carriers,  and 
24  to  30  centimetres  (9  to  12  inches)  for  liga- 
tures and  sutures.  Some  of  these  are  wound 
on  a  glass  reel ;  and  a  few  such,  of  assorted 
sizes,  are  dropped  into  a  stout  glass  ignition- 
tube  devised  for  this  puipose.  Several  of 
these  tubes,  plugged  loosely  with  cotton,  are 
put  into  a  steam  sterilizer  for  an  hour  the 
first  day,  and  on  the  two  following  days  for 
half  an  hour  each  time.  The  steam  passes 
through  the  cotton  without  restraint,  and  acts 
upon  the  silk  as  easily  as  if  it  lay  loose  in  the 
sterilizer.  On  removing  the  tubes  the  cotton 
in  the  mouth  is  pushed  tightly  in,  and  they 
are  stored  away  in  glass  jars  until  wanted. 
Silk  which  remains  over  after  an  operation 
may  be  resterilized  in  the  same  way,  but  it  is  apt  to  be  weakened  after  the 

*  The  author  has  almost  entirely  abandoned  the  use  of  silk  iu  his  technique  in 
pelvic  operations. 


Fig.  96.  —  Small  Vapuuk 
Sterilizer  for  Privatk 
Installation. 


120 


DISEASES   OF   WOMEN. 


second   sterilization. 


Fig.  97. — Glass  Keel  to  keep  Gvt  in 
soltttion. 


Oftnfor  use. 


I  fncl  lhe  hermetically  closed  glass  jars  of  Leiter 
admirable  for  preserving  the 
silk. 

Bergmann,  of  Berlin,  places 
the  catgut  in  1  per  cent,  sub- 
limate   solution  and   80   per 
cent,  of  alcohol.     It  is  left 
for  at  least  48  hours.     This 
immersion  is  renewed  in  fresh 
solution  every  few  days  until 
the  fluid  is  quite  clear ;  then 
the  gut  is   kept  in  ordinary 
alcohol. 
Hofmeister,  of  Tubingen,  proceeds 
as  follows  :  The  raw  catgut  is  wound 
without   any   preparation   on    strong 
glass   plates   or  reels,    so   that   each 
thread  lies  next  to  the  other.     The 
thread  must  be  carefully  and,  tightly 
wound,  and  the  ends  are  best  knotted. 
The  rolled-up  catgut  is  then  placed — 

1.  For  12  to  48  hours  in  a  2  to  4 
per  cent,  formalin  solution. 

2.  Tn  running  water  for  12  hours, 
to  get  rid  of  the  superfluous  formalin. 

3.  It  is  boiled  in  water  for  10  to  20 
minutes. 

4.  It  is  hardened   and  kept  in  a 
mixture  of  absolute  alcohol,  with  5 


Fig.     98.  —  Leitek's     Hermetically   per  cent,  of  glycerine,  and  either  4 
Closed  Vulcanite  and  Glass  Jar   per  cent,  carbolic  acid  or  1  per  cent. 

corrosive  sublimate. 


FOR  six  Silk  Eeels,  containing  six 
Different  Sizes  of  Silk. 


Silkworm   G-ut. — To    sterilize 
silkworm  gut,  a  dozen  pieces  or 
more    are     loosely    twisted     to- 
gether, doubled,  and  put  into  an 
ignition-tube  or  a  piece  of  igni- 
tion glass  tubing  plugged  at  both 
Fig  99.-A  Vulcanite  Cap,  WHICH  FITS    ^^^^     ^^^  sterilized  in  the  same 
Air-tight,  is  secured  by  the  Cen- 
tral  Screw,  and  covers  the  Silk.     ^^7  ^^  ^"®  ^^^^' 

Celloidinzwirn,  —  Celloidinz- 

wirn  is  a  very  strong  white  thread  of  cotton  impregnated  with 
celloidin.  It  has  the  advantage  over  silk  of  cheapness  and  power 
of  resistance  to  heat  sterilization.  The  celloidin  increases  greatly 
the  strength  of  the  thread.     It  was 'first  recommended  by  T.  Braun, 


ASEPSIS  AND  ANTISEPSIS  ilV  G7NJEC0L0GICAL   SURGERY.     121 

and  is  prepared  in  exact  accordance  with  his  instructions  Ijy 
Schaedel  of  Leipzii,'.*  It  must  be  boiled  or  sterilized  by  steam 
before  use,  and  then  kept  in  perchloride  solution.  It  can  be  used 
both  for  superficial  and  deep  sutures  and  ligatures.  Not  having  the 
elasticity  of  silk,  too  great  a  strain  must  not  be  put  on  it  in  tying,  f 
Bronze- Aluminium  Wire. — This  wire  I  first  saw  used  by  Professor 
Bumm  in  Halle.  I  have  employed  it  in  several  cases.  It  makes  an 
admii-able  suture  for  the  skin.     It  can  be  sterilized  with  the  other 


Fig.  100.— Glass  Needle-c.\se  foe  keeping  Sterilized  Xeedles. 


instruments.  It  causes  no  irritation,  and  can  be  allowed  to  remain 
for  a  fortnight  if  necessary.  It  may  be  used  as  a  continuous  suture. 
Sponges. — The  difficulty  in  thoroughly  sterilizing  sponges  has,  I 
think  rightly,  led  to  the  rejection  of  them  by  most  surgeons.  At 
the  same  time,  if  we  can  secure  such  sterilization,  a  sponge  is  for 
some  purpo.ses  the  most  absorptive  material  we  can  use.  No  matter 
how  guaranteed  by  a  chemist  or  instrument-maker,  the  surgeon 
should  himself  secure  the  purity  of  the  sponge  before  he  uses  it. 
The  prepared  and  compressed  sponges  sold  by  most  instrument- 
makers,  when  soaked  in  boiling  water  and  placed  for  some  hours  in 
a  five  per  cent,  solution  of  carbolic  acid,  are  among  the  best.  The 
precautions  of  soaking  every  newly  purchased  sponge  in  boiling 
water,  and,  after  it  has  lain  in  it  for  some  time,  allowing  it  to  lie  for 
a  few  hours  in  a  strong  carbolic  or  perchloride  solution,  should  at 
least  be  observed.  A  perfect  sponge  is  of  that  size  to  be  grasped 
conveniently  in  the  fingers,  and  to  absorb  a  sufficient  quantity  of 
fluid.  Those  sold  are  often  too  small.  They  should  not  be  too 
porous  nor  readily  tearable,  neither  should  they  feel  hard,  coarse,  or 
rough.     The  sponge  should  be  complete  in  itself. 

*  Alexander  Schaedel,  Reichstrasse  14,  Leipzig.  This  material  I  now  use 
almost  altogether  in  suturing  the  skin;  only  very  rarely  do  I  employ  the 
bronze-aluminium. 

t  Miinchen.  med.  Wochemclirijt,  Nos.  14  and  15. 


122  DISEASES   OF   WOMEN. 

In  Johns  Hopkins  Hospital  the  process  followed  for  preparing  sponges  is 
as  follows : — 

'  1.  Lay  them  in  a  stout  cloth  and  pound  sufficiently  to  break  up  grit  and  lime. 

'  2.  Einse  with  warm  water  ten  or  more  times  until  it  remains  clear. 

'3.  Immerse  in  a  muriatic  acid  solution,  15  cubic  centimetres  to  1  litre 
(3  ij  to  0  j.),  for  twenty-four  hours. 

'  4.  Immerse  in  saturated  warm  permanganate  of  potash  solution. 

'  5.  Decolourize  in  a  hot  saturated  oxalic  acid  solution. 

'  6.  Pass  through  lime-water  to  take  out  all  the  oxalic  acid. 

'  7.  Einse  thoroughly  in  plain  sterilized  water. 

'  8.  Immerse  in  a  1  in  1000  solution  of  bichloride  of  mercury  for  twenty- 
four  hours. 

'  9.  Preserve,  until  used,  in  a  3  per  cent,  carbolic  acid  solution.' 

'  The  hands  manipulating  the  sponges  during  these  preparations,  from  step  4 
on,  must  be  sterile,  and  much  of  the  manipulation  may  be  done  with  instruments. 

'  When  wanted  for  use  the  sponges  are  lifted  out  with  a  long  pair  of 
sterilized  forceps  and  rinsed  in  sterilized  water.  I  never  use  the  same  sponge 
twice,  although  this  may  be  safely  done  after  aseptic  operations.' 

'  Iodoform  Gaixze  is  prepared  (with  aseptic  hands)  by  rolling  plain  sterilized 
gauze  in  3-metre  (about  3-yard)  lengths,  and  then  cutting  up  the  roll  into 
different  lengths  and  breadths  to  meet  the  various  requirements. 

'  Before  dividing  the  large  roll  into  these  smaller  pieces,  it  is  saturated 
with  the  following  iodoform  mixture :  To  180  cubic  centimetres  (6  ounces) 
of  warm  water,  made  into  a  good  suds  with  Castile  soap,  add  45  cubic  centi- 
metres (an  ounce  and  a  half)  of  powdered  iodoform,  and  mis  it  well  in  a 
clean  basin  with  a  glass  rod.  Then  immerse  the  roll  of  gauze  in  the  hquid, 
and  work  it  with  the  hands  until  the  iodoform  has  been  completely  taken  up 
into  the  meshes  of  the  roll.  This  is  now  sterihzed  three  times  in  the  steam 
sterilizer.' 

Drainage-tubes  are  best  treated  by  placing  them  in  the  sterilizer 
used  for  the  dressings.  When  taken  out  they  can  be  kept  in  car- 
bolic acid  solution  5  per  cent.  Just  before  use  they  should  be 
washed  in  sterilized  water  and  transferred  to  a  2  per  cent,  formalin 
solution.  Glass  drainage-tubes  are  placed  with  the  instruments  in 
the  dry  sterilizer. 

Sterilization  of  Large  Compresses. — Additional  security  for  the  preparation 
of  the  larger  compresses  when  the  muslin  is  new,  can  be  had  by  boiling  them 
in  a  solution  of  permanganate  of  potash  for  about  half  an  hour,  after  which 
they  are  treated  with  bisulphite  of  sodium  in  order  to  decolorize  them.  Two 
litres  of  1  in  1000  permanganate  solution  are  calculated  for  about  2  ozs.  in 
weight  of  sponges.  The  latter  are  washed  with  sterilized  water,  after  some 
hours'  resting  in  the  permanganate  liquid,  so  as  to  free  them  from  the  pre- 
cipitate of  oxide  of  manganese.  About  9  ozs.  of  a  10  per  cent,  solution  of 
bisulphite  of  sodium  in  the  2  litres  of  water  will  be  required  to  thoroughly 
decolorize  the  sponges,  and  1  dram  of  pure  hydrochloric  acid  is  added  to  the 
solution.     They  are  then  washed  in  boiling  water,  so  as  to  remove  every 


ASEPSIS  AXD  AXTISEPSIS  IN  GYN2EC0L0GICAL   SURGERY.     123 


trace  of  sulphurous  acid,  when  tliey  are  dried  and  sterilized  in  the  Pouijinel 
stove.  They  can  then  he  kept  either  in  a  solution  of  carliolic  acid  or  sub- 
limate. If  ordinary  sponges  be  used,  they  should  be  prepared  by  the  per- 
manganate of  potash  method,  followed  by  decolorizatiou  with  either  oxalic 
acid  or  bisulphite  of  sodium,  thorough  washing  with  sterilized  water,  and 
retention  until  required  for  use  in  a  5  per  cent,  carbolic  solution.  It  may 
be  well  always  to  have  some  such  sponges  at  hand,  more  particularly  the 
larger  and  flatter  ones. 

Air-tight  aseptic  containers  for  medicated  bandages,  dressings,  and  gauzes, 
as  well  as  aseptic  ligatures  of  various  lengths  prepared  in  sterilized  capsules 
and  heated  in  cumol  at  a  temperature  of  330°  Fahrenheit,  can  be  had. 
They  have  the  advantage  of  porta- 
bility, and  are  guaranteed  to  resist  any 
bacteriological  test.* 


Preparation  of  the  Surgeon  and 
his  Assistants. 

The  requirements  of  ordinary 
cleanliness,  such  as  frequent  bath- 
ing, changes  of  underlinen,  etc., 
are  naturally  stringently  binding 
on  the  surgeon,  but  they  are  not 
all  he  has  to  consider.  For  operat- 
ing he  should  be  dressed  in  a  clean, 
preferably  sterilized,  suit,  or  jacket 
and  apron,  and  the  arms  should  be 
bare  from  well  above  the  elbows 
downwards.  The  same  remark  ap- 
plies to  his  assistants.  Nurses 
should  wear  clean  linen  over-all 
aprons,  and  have  their  arms  bare. 
For  the  proper  disinfection  of  the 
hands  of  operator,  assistants,  and 
nurses,  minute  precautions  are  ne- 
cessary. 

As  to  the  surgeon's,  assistants', 
and  nurses'  arms  and  hands,  it  may 
be  safely  said  that  it  takes  at  the 
very  least  ten  minutes'  time  to  pre- 
pare these.  Preferably,  they  should 
be  washed  (from  above  the  elboivs  down)  under  a  tap  of  running 

*  The  containers  and  dressings  are  made  by  Messrs.  Seabury  and  Jolinson. 


Fig.  101. — Assistant  ready  for 
Operatiox. 

Underneath  the  overall  is  a  "  com- 
bination "  suit  of  linen. 


124 


DISEASES   OF   WOMEN. 


lysoform,  and  with  Izal  soap.  The  nail-brushes  should  be  kept 
always  in  antiseptic  fluid  in  air-tight  glass  boxes  (which  are  now 
easily  obtainable),  to  the  covers  of  which  they  are  screwed,  being 
thus  constantly  soaked  in  the  antiseptic.  The  glass  cover  thus 
forms  the  back  of  the  brush.  The  arms  should  be  several  times 
well  soaped  as  well  as  the  hands,  with  nails  closely  pared,  and  sub- 
jected to  repeated  cleans- 
ings,  and  the  arms  and 
hands  both  finally  scrubbed 
over  with  1  in  1000  sub- 
limate solution.  Then  the 
hands,  ivrists,  and  arms  are 
pressed  down  and  hept  for 
a  few  minutes  in  a  hasin  of 
equal  parts  of  sublimate  so- 
lution (1  in  1000)  and  ab- 
solute alcohol,  ivhich  solution 
is  also  carried  over  the 
arms.  The  hands  of  the 
operator,  his  immediate  as- 
sistant, the  overseer  of  the 
instruments  and  ligatures, 
or  those  of  any  nurse  who 
may  have  to  handle  instru- 
ments, sponges,  or  dress- 
ings, should  be  prepared 
with  equal  care.  There 
should  also  be,  at  the  side 
of  the  operator,  a  small 
washstand,  or  preferably  a 
movable  lavabo  on  castors, 
which  has  two  jars  pro- 
vided with  taps  over  basins 
containing  sterilized  water 
and  lysoform,  in  which  his 
hands  can  be  rinsed  from  time  to  time  during  the  operation. 

Some  surgeons  prefer  the  permanganate  of  potash  and  oxalic- 
acid  method  of  disinfecting  the  hands.  The  efl&cacy  of  the  method 
was  tested  by  Ghriskey  and  Robb  at  the  Johns  Hopkins  Hospital, 
and  it  was  proved  that  by  far  the  more  powerful  of  the  two 
germicides  is  oxalic  acid. 


Fig.  102.— Scegeon  with  Oveealls  and 
Wateepeoof  Aeeox  pbepaeed  foe  Va- 
ginal Operation. 


ASEPSIS  AXD   AXTISEl'SIS   LX   (iVX.ECOLOd ICAL    SURtlEIlY.     12.t 


Absolute  Alcohol. — The  experiments  of  Ahlfeld,  Eeineicke,  and 
Poten,  confirmed  by  Fuerbringer  and  Freyliau,  showed  that  the 
bactericidal  properties  of  alcohol,  in  combination  with  corrosive 
sublimate,  are  to  be  ascribed  to  the  removal  of  the  fat  of  the  skin  of 
the  hand,  while  its  power  of  uniting  with  water  renders  disinfection 


■■■■BMIlllllllMIWIMIIllllllllllllllllllllllllimiillil' 

jYfTTTTJlTl 


'lllWT'llt'lifl'TjTrir.. ,111111-  i]i|niii(rn»<Ti  ■iiii. 


Fig.  103. — Aseptic  Nail-brush  with  Box. 

These  brushes  should  always  be  kept  in  the  theatre  uuder  lock  and  key  ;  the 
box  filled  with  1  in  1000  of  formalin. 

of  the  tissues  easy  by  the  associated  sublimate  or  its  subsequent 
solution,  at  the  same  time  that  the  squamous  epithelium  and  the 
superficial  impurities  as  well  as  the  bacilli  are  removed.  The  arms 
should  be  washed  with  the  mercuric  and  alcohol  solution,  and  the 
hands  immersed  in  it  for  some  two  minutes  before  their  sterilization 
is  complete. 


Antiseptics. 

The  best  antiseptics  are  lysoform,  carbolic  acid,  corrosive  subli- 
mate, ethylene-diamine  mercuric-citrate,  formalin,  iodoform,  lysol, 
napthol  B,  dermatol.  Ethylene-diamine  mercuric-citrate  has  a 
greater  power  of  penetration  and  less  injurious  action  on  the  skin 
of  the  hands  than  the  perchloride.  It  is  weaker  than  perchloride, 
3  in  1000  being  equal  to  1  in  1000  of  the  perchloride.* 

Tt  is  asserted  for  traunudol  that  its  antiseptic  power  is  as  strong  as  corro- 
sive sublimate,  and  from  experiments  made  comparatively  with  iodoform 
upon  cultivations  of  the  Sfaphyhroccus  aureus  by  dusting  these  with  the 
powder,  the  traumatol-treated  cultures  were  not  liquified  before  the  eleventh 
day,  whereas  the  iodoform  ones  were  completely  liquified  in  forty-eight 
hours.  The  injection  of  guinea-pigs  with  traumatol  has  proved  how  innoculous 
it  is  as  compared  with  iodoform,  and  similarly  in  the  case  of  its  internal 
administration.  It  is  an  iodocresylic  acid,  and  contains  54-4  per  cent,  of 
iodine,  in  combination  with  cresylic  acid.      Its  bactericidal  action  would 

*  '  Chemisch  Fabrik  auf  Actien,'  E.  Schering,  Berlin. 


126  BISEASES   OF   WOMEX. 

appear  to  depend  more  upon  the  cresylic  acid  tlian  on  the  iodine,  as  it  con- 
tains much  less  iodine  than  the  iodoform.  It  has  not  the  disagreeable  odour 
of  iodoform,  but  rather  an  aromatic  smell.     I  frequently  use  dermatol. 

Corrosive  Suhlimate  I  only  use  for  sterilization  of  the  hands  and 
the  skin  of  the  abdomen,  or  in  sterilization  of  the  vagina.  Lysoform 
I  now  use  largely  in  the  preparation  of  the  hands,  for  douching,  and 
for  washing  the  abdomen.  Formalin  I  employ  largely  in  the  strength 
of  1  in  1000  for  cleansing  of  the  hands  in  post-operative  dressings 
of  wounds  for  the  first  few  times,  for  vaginal  douchings,  in  the 
separation  of  sutures,  and,  when  there  are  septic  discharges,  for  the 
cleansing  of  sinuses  (when  I  employ  a  strength  of  1  per  cent.). 
Weak  solutions  1  in  5000  to  1  in  10,000  I  have  frequently  used  in 
abdominal  irrigations.  I  also  generally  make  it  my  first  dressing 
after  laparotomy,  moistening  the  sterilized  iodoform  gauze  in  it. 
Formalin  in  vapour  I  avail  of  in  the  larger  "  Alformant "  lamps  for 
my  operation-room  and  clothes  cupboard.  Drainage-tubes  are  im- 
mersed in  a  solution  of  1  per  cent,  before  they  are  inserted.  Glass 
catheters  are  always  kept  in  formalin  solution,  two  being  used  with 
every  case  in  which  catheterization  is  necessary,  one  being  taken 
fresh  each  time  from  the  formalin  solution.  Lysoform :  For 
ordinary  douchings  of  the  vagina  I  use  lysoform,  and  employ 
entirely  lysoform  or  izal  soap  for  washing  purposes,  Oarholic  acid, 
save  for  keeping  silk,  drainage-tubes,  taps,  douche-pipes,  and  other 
appliances  in,  I  never  employ. 

Asepsis  :  General  Observations  on. — During  an  operation,  asepsis 
means  scrupulous  care  in  the  placing  and  replacing  of  instruments, 
the  occasional  dipping  or  boiling  of  these  if  necessary,  periodical 
cleansing  of  the  hands  of  the  surgeons  and  assistants  (each  of  the 
latter  being  confined  to  his  own  special  duties),  the  rejection  of 
instruments  not  re-sterilized,  needles  or  others  that  may  possibly 
have  been  infected  in  any  step  of -the  operation,  the  flushing  and 
cleansing  as  far  as  possible  of  infected  areas  and  cavities  with  weak 
formalin  fluid,  rapid  and  effective  hfemostasis,  with  final  cleansing 
from  all  remains  of  blood  or  coagula,  and  then  proceeding  to  the 
abdominal  toilet  with  freshly  cleansed  hands  and  thoroughly 
cleansed  tissues  and  skin.  Lastly,  in  the  abdominal  toilet  itself, 
careful  adjustment  of  the  layers,  and  the  use  for  the  cutaneous 
wound  of  sterilized  non-absorbable  material. 

Wliat,  then,  are  the  most  important  essentials  in  obtaining  an  ideal 
gynaecological  asepsis  f  And  first  we  have  to  answer  the  question. 
Is  such  an  ideal  perfection  possible?     I  fear  it  is  not,  or  at  least 


ASEPSIS  AND  ANTISEPSIS  IX  GYNECOLOGICAL   SURGERY.     127 

that  it  can  seldom  be  reached.     This  arises  from  a  threefold  cause. 
There  is  the  impossibility,  even  by  the  most  carefully  carried  out 
antisepsis,  of  entirely  excluding  germs  fx'om  the  skin  wound  and 
from  the  vagina,  more  particularly  if  in  the  latter  there  be  any 
abraded  surfaces,  and  that  pathogenic  organisms  be  present  from 
uteiine  erosions  and  discharges,  as  well  as  in  those  septic  states  met 
with  in  many  abdominal  and  pelvic  operations  from  which  infection 
may  spread.     Secondly,  there  are  predisposing  influences  which  may 
be  entirely  outside   the    power  of    any  anticipatory  or  preventive 
measures  to  control.     "We  have  examples  of  this  in  the  proneness  to 
suppuration  in  certain  individuals,  due  either  to  some  condition  of 
the    tissues    favourable   to    microbal   growth,    or    to    some    special 
virulence  and  toxic  properties  in  the  pyogenic  organisms  present,  or 
in  the  toxic  matters  to  which  they  give  rise.     Here   we   have  to 
take  into  account  lowered  vitality  and  defective  powers  of  resist- 
ance on  the  part  of  the  individual  and  the  tissues,  lessening  any 
ordinary  protective  influence  against  septic  invasion.     Lastly,  there 
are  the  many  avenues  through  which  infection  may  be  admitted  by 
even  the  most  careful  of  nurses,  assistants,  and  surgeons, — through 
some  defect  in  the  preliminary  precautions,  the  surrounding  atmo- 
sphere, the  appKances  in  the  operating-room  ;  the  instruments,  some 
•oversight   or  carelessness   on   the   part   of    the  nurse,    surgeon,   or 
assistants  during  the  operation  ;  defective  sterilization  of  water,  or 
through  any  source  of  infection  that  may  be  overlooked  in  the  final 
toilet  and  dressing  of  the  wound. 

In  view  of  so  many  means  of  admission  of  infection,  it  is  obvious 
how  difficult  is  the  attempt  to  obtain  such  an  ideal  asepsis  as  will 
secure  for  us  the  absence  of  septic  germs  from  a  wound.  The 
recognition  of  this  difficulty  is  the  first  step  in  the  education  of 
both  surgeon  and  nurse,  and  if  this  be  true  under  ordinary  circum- 
stances, how  much  greater  must  be  the  care  taken  and  the  pre- 
cautions adopted,  when  either  nurse  or  surgeon  is  brought  in  contact 
with  any  septic  case  within  a  given  time  before  the  operation. 
This  involves  on  the  part  of  both  not  merely  preparation  immediately 
before  the  operation  takes  place,  whether  in  an  ordinary  room  or 
operating  theatre,  but  exceptional  pi-ecautions  in  private  in  regard 
to  the  cleansing  of  the  arms  and  hands,  as  well  as  the  use  of  fresh 
underclothing  and  linen  on  the  day  of  an  operation. 

Ideal  asepsis,  therefore,  presupposes  a  perfectly  constructed  theatre 
with  every  aseptic  appliance,  and  the  most  scrupulous  attention 
to  details  in  the  persons  and  surroundings  of  the  operator,  assistants, 


128  DISEASES   OF    WOMEN. 

and  nurses.  Summarising  these,  they  include  a  theatre  capable  of 
being  well  ventilated,  at  a  temperature  of  100^,  with  a  supply  of 
filtered  aii',  well  lighted,  with  tiled  walls,  and  a  concreted  and 
drained  floor,  perfectly  trapped,  thus  enabling  all  fluid  to  run  from 
it  without  any  possibility  of  infective  reflux  of  gases  ;  all  washing 
sinks  and  baskets  for  dressings  worked  by  foot-pedal,  and  all  the 
appliances  capable  of  disinfection  or  sterilization.  It  also  involves 
the  complete  sterilization  of  every  material,  whether  in  clothing  ■ 
worn  by  the  patient  or  nurses,  towels,  bandages,  compresses,  dabs, 
sponges,  and  dressings.  With  regard  to  the  preparation  of  the 
hands  of  the  surgeon,  assistants,  and  nurses,  it  takes  for  granted 
perfect  sterilization  of  the  arms,  hands,  and  nails,  not  only  before, 
but  all  through  an  operation,  and  the  same  may  be  said  of  the 
appliances  and  instruments  used  in  conducting  it.  In  such  a 
theatre,  and  under  these  conditions,  if  the  patient  be  properly 
prepared,  an  asepsis  that  may  be  called  ideal  can  be  secured. 

Preparation  of  the  Patient. 

Sterilization  of  the  Abdomen. — All  preparations  should  be  con- 
cealed from  the  patient,  and  if  possible  the  anaesthetic  should  be 
administered  in  an  adjoining  room.  When  the  patient  is  placed  on 
the  operating-table,  all  dressings  and  appliances  should  be  in  their 
right  places.  The  needles  and  ligatures  are  assorted,  the  accessory 
requisites  ai'e  all  placed,  the  small  forcipressure  forceps  are  coujated. 
Each  assistant  and  nurse  is  in  his  or  her  proper  position.  From 
this  moment  to  the  conclusion  of  the  operation  there  should  be  no 
speaking,  and  only  the  operator's  voice,  in  addressing  his  immediate 
assistant,  should  be  heard. 

What  is  involved  in  the  jjreparatlon  of  a  patient  f  We  may 
include  previous  thorough  ablutioji  of  the  body,  with  careful 
shaving  of  the  part,  proper  emptying  and  disinfection  of  the  bowel, 
softening  and  disinfection  of  the  skin  of  the  abdomen,  with  thorough 
cleansing  and  disinfection  of  the  vagina,  and  curettage  of  the 
uterine  canal  when  necessary. 

Coming  to  the  immediate  prejyarations,  if  these  be  done  in  the 
theatre  or  an  apartment  adjoining,  under  the  conditions  mentioned, 
the  body  of  the  patient  (nude,  save  for  the  aseptically  covered 
upper  and  lower  extremities)  can  be  thoroughly  disinfected  by 
lavements  with  wood  fibre  sponge  and  izal  or  lysoform  soap,  from 
the  thorax  to   the  thighs,   first  with   sterilized  water,   next  with 


PLATE    IX. 


J 


Patient  prepared  for  Operation — Woollen  Jacket,  Muslin  Slips  held  by 
Light  Clamp  or  Sponge  Holders;  Sack  Drawers  are  drawn  over 
Woollen  Stockings  (all  Sterilized).    (See  p.  129.) 


Same  in  Partial  Trendelenburg  Position. 


IToface  p.  128. 


A.^TPSIS   A.\J>   AXTTSEP.-^lf^  AV  iiYXjECOLOOTCAL    SURGERY.     12!t 

sublimate  solution,  followed  by  sublimate  and  absolute  alcohol, 
and  finally  ether.  This  should  be  done  by  an  assistant,  and  with 
rubber  gloves.  Strrllized  sack  drawers  arc  then  draion  over  the 
Jiannel  handaijex  tchlch  have  been  previously  applied,  the  drawers 
reaching  to  the  <jroin,  and  there  looseli/  tied.  A  sterilized  flannel 
Jacket  opening  behind  is  then  slip]ped  over  the  trunJc.  Three  pieces  of 
soft  )iiuslin  material,  about  two  yards  long  by  half  a  yard  loide,  are 
next  taken,  one  having  an  oval  aperture  cut  in  the  centre  for  the 
abdomen.  The  first  is  laid  across  the  loiver  part  of  the  abdomen,  and 
cover.^  the  drawers;  the  second  is  placed  with  the  aperture  over  the 
operative  area;  the  third  meets  the  Jacket,  covering  the  chest  above.  All 
three  are  clamped  together  at  the  sides  by  sterilized  sponge-holders 
or  clamp  forceps.  These  keep  the  coverings  immovable  during  the 
operation.     If  soiled  during  the  operation  they  are  readily  replaced. 

As  little  of  the  surface  of  the  part  to  be  operated  upon  as  is 
possible  is  exposed  before  the  first  incision  is  made.  For  example, 
in  oophorectomy  or  removal  of  the  appendix  it  is  not  necessary  to 
bare  more  than  a  few  inches,  the  needful  space  being  left  uncovered 
by  placing  the  small  aseptic  cloths,  taken  straight  from  the  steri- 
lizer, around  the  area  of  the  wound.  All  the  compresses  and  gauze 
dressings,  as  well  as  the  sponges,  are  in  like  manner  taken  straight 
from  the  pedal-boxes,  out  of  the  sterilizer,  and  these  compresses  and 
dressings  are  alone  used  (without  any  disinfectant)  for  hsemostasis, 
for  tampons,  the  exclusion  of  the  intestines,  and  the  protection  of 
organs  and  vessels.  The  compresses  are  easily  caught  with  a  catch 
forceps,  which  is  thrown  over  the  edge  of  the  wound  so  as  to  facili- 
tate removal. 

Sterilization  of  the  Vagina  and  Cervical  Canal. — With  regard  to 
the  vagina,  after  careful  washing  of  the  external  genitals  with  Holz- 
icolle  sponge  (Waschel)  and  antiseptic  soap,  which  is  continued  with 


Fig.  104. — Nickkl-plated  Yagixa  Douchk  Pipk. 


alternate  douching  for  a  few  minutes,  the  vaginal  walls  internally  are 
well  lathei-ed  with  the  same  and  washed  with  repeated  douchings. 
This  is  done  with  the  sterilized  hand  of  the  nurse.    The  whole  canal  is 

K 


130 


DISEASES   OF     WOMEN. 


then  repeatedly  mopped  out  with  gauze  mercurialized  dabs  on  sponge- 
holders.  If  the  cervical  canal  has  to  be  sterilized  the  uterine  neck 
is  seized  with  tenacula,  and  drawn  well  down.  Martin's  curette  is 
next  used  to  the  uterine  canal,  which  is  then  douched  out  with  the 
antiseptic  solution,  iodine,  lysol,  or  other,  as  may  be  selected,  or  it 
is  mopped  out  with  a  20-gr.  to  the  ounce  solution  of  chromic  acid. 
The  vagina  and  cervix  are  thus  sterilized.  After  sterilization  of  the 
cervical  canal,  it  is  the  practice  of  some  gynaecologists  to  amputate 
the  lower  portion  of  the  cervix,  and  then  suture  the  divided  lips 
together.  Others  prefer  the  use  of  Paquelin's  or  the  porcelain 
gal  vano-cautery . 


Fig.  105. — Flushing  Vagixal  Eetractor. 


Fig.  105a. — Tap  with  Adjustable  Nozzle. 

A  most  valuable  instrument  for  all  vaginal  operations  is  the 
flushing  vaginal  retractor.  It  is  an  admirable  instrument,  and 
is  always  under  the  control  of  one  of  the  assistants.  A  tube 
connects  it  with  the  douche  reservoir,  and  the  strength  of  the  stream 
is  regulated  by  a  stop-cock. 

Precautions  regarding  Nurses. — Two  nurses  are  placed  a  little 
behind  and  to  the  operator's  right,  one  for  the  immediate  passing  of 
sponges,  dabs,  tampons,  etc.  The  second  nurse  passes  to  her  all 
such  fresh  gauze  or  other  dressings,  and,  if  ordinary  sponges  are  used, 
she  sees  to  the  rinsing  and  return  of  these.  Neither  of  these  nurses 
should,  before  final  sterilization  of  the  hands  and  arms,  touch  anything 
in  the  shape  of  an  instrument,  appliance,  sponge,  cloth,  or  dressing  used 
in  the  operation.  Should  only  two  nurses  be  available,  the  one  who 
places  the  patient  on  the  table,  and  sees  to  the  arrangement  of  the 
clothes  and  coverings,  should  sterilize  both  hands  and  arms  before 
taking  her  place  at  the  operation. 


ASEPSIS  AX  J)   AXTISEPSIS   IX  GrXJECOLOGICAL   SURGERY.     131 

The  rules  I  insist  on  for  nurses  are  as  follows  : — 

One  nurse  prepares  the  patient,  as  instructed,  on  the  morning  of  the 
operation.  She  sees  to  the  shaving,  loashing,  and  disinfection  of  the 
case,  and  the  bringing  of  the  patient  into  the  operating-room.  She  sees 
to  the  arrangement  of  her  clothes  ivhen  on  the  table.  She  does  not 
touch,  from  first  to  last,  anything,  whether  instrument,  sponge,  compress, 
or  dressing,  ivhich  is  used  in  the  operation. 

She  sees  to  the  different  aprons  and  overalls  *  for  the  doctors,  she 
stands  by  during  the  operation,  but  does  not  tahe  part  in  any  manipula- 
tion concerned  with  the  operation  itself,  or  the  appliances.  This  rule  is 
never  infringed. 

Aseptic  Nurses. — Nurse  No.  1  is  responsible  for  the  previous  sterili- 
zation of  everything  which  is  used,  or  that  may  be  required  to  be  used, 
during  an  operation.  She  is  careful  that  nothing  which  has  not  been 
sterilized  can  possibly  come  ivithin  reach  of  the  operator  or  assistants. 
She  tahes  charge  of  all  sponges  or  compresses,  and  hands  them  directly 
to  the  operator  or  assistant,  standing  immediately  behind  him.  If  ordi- 
nary sponges  are  at  any  time  used,  she  passes  these  to  the  second  nurse 
for  rinsing  and  returning.  She  is  responsible  for  the  counting  of  sponges 
(should  such  be  used)  and  torsion  forceps. 

Nurse  No.  2  stands  near  No.  1,  and  is  ready  to  assist  with  dabs  and 
irrigator,  or  anything  that  may  be  directly  required  in  the  operation  itself. 
No  nurse  talcing  a  direct  part  in  the  operation  is,  during  its  progress,  to 
pick  up  anything  dropped  on  the  floor.  No  nurse  is  to  assist  who  has  any 
infectious  wound  or  sore  on  the  hand,  or  loho  suffers  from  cold  in  the  head. 

After  the  hands  and  nails  of  the  two  nurses  assisting  have  been 
rendered  thoroughly  aseptic,  they  must  not  touch  ariything  ivhich  has  not 
been  sterilized. 

Another  nurse  assists  immediately  after  the  operation  in  the  thorough 
cleansing  and  drying  of  the  instruments. 

Causes  of  Failure. — It  is  well  to  enumerate  and  emphasize 
what  are  the  principal  causes  of  failure  in  securing  thorough  asepsis. 
(1)  Defective  sterilization  of  the  rectum  and  vagina  for  at  least 
forty-eight  hours  prior  to  operating. 

In  the  instance  of  the  rectum  this  is  avoided  by  the  use  of  saline 
aperients,  a  dose  of  calomel,  and  lavage  of  the  rectum  with  1  in  1000 
of  permanganate  of  potash  in  sterilized  water,  or  a  stei'ilized  solution 
of  boric  acid,  and  of  the  vagina  by  thorough  washing  out  with  1  in 
1000  of  formalin  solution,  lysol,  formalin  or  perchloride  of  mercury, 

*  All  necessary  overalls  and  aprons  can  be  had  ready  made  of  Messrs.  Bohme, 
54,  Orienberger  Strasse,  Berlin,  and  M.  Turinsky,  Garrison  Strasse,  Vienna. 


132  DISEASES   OF   WOMEN. 


followed  by  the  insertion  of  a  tampon  or  sterilized  iodoform  chinosol 
gauze. 

(2)  The  ivant  of  thorough  cleansing  of  the  entire  body  of  the  patient  by 
the  use  of  a  warm  bath,  in  which  the  skin  is  well  scrubbed  with  lysol 
soap,  (3)  Defective  shaving  of  the  entire  hair  of  the  external  genitals 
after  the  final  bath  has  been  taken,  this  being  followed  by  proper 
packing  of  the  abdomen  with  an  antiseptic  pad,  such  as  1  in  1000 
of  formalin.  (4)  Want  of  attention  to  the  clothing  of  the  patient  when 
placed  on  the  operating-table,  as  to  its  warmth  and  cleanliness,  and 
omitting  to  see  that  the  feet  and  legs  are  well  enveloped  in  sterilized 
flannel  bandages.  (5)  Inefficient  sterilization  of  the  abdomen  (espe- 
cially of  the  umbilicus)  or  of  the  vagina — of  the  abdomen  and 
uinbilicus  by  a  special  washing  when  on  the  table  with  lysol  soap 
and  a  brush,  perchloride  of  mercury  with  alcohol,  and  finally  ether 
the  vagina  I  shall  refer  to  again.  (6)  Inefficient  sterilization  of  the 
hands  and  arms  of  the  surgeon,  assistants,  or  nurses,  or,  subsequent  to 
their  sterilization,  the  touching  or  handling  of  non-sterilized  articles. 

It  is  obviously  ridiculous  to  see  a  surgeon  who  has  prepared  his  hands 
making  a  resting-place  for  them  on  his  hips,  search  in  his  waistcoat-pockets 
for  a  knife  or  pencil,  place  them  on  the  sides  of  a  chair  or  stool,  twirl  his 
moustache,  or  use  a  pocket-handkerchief ;  hut  even  worse  acts  of  forgetful- 
ness  than  these  have  been  noticed  and  commented  upon  bj'  those  who  have 
visited  some  of  our  operative  theatres. 

As  yet  it  is  difficult  to  get  the  thoroughly  trained  aseptic  nurse.  It  is 
pitiable  that  women  are  still  turned  out  from  their  probationary  course  of 
training  in  such  absolute  ignorance  of  what  should  be  the  most  essential  part 
of  their  education.  It  is  no  uncommon  thing  to  find  gynaecological  trained 
nurses  preparing  for  an  operation  or  dressings  with  long  sleeves  and  cuffs, 
handling  promiscuously  the  clothes  or  coverings  of  a  patient  and  dressings  or 
appliances,  with  the  crudest  ideas  of  sterilization,  and  a  happy  but  reckless 
disregard  in  the  handling  of  antiseptic  dressings  ;  the  mixing  of  non-sterilized 
Avith  sterilized  water,  in  the  using  of  cans  and  taps  ;  in  washing  tvith  nail- 
hrushes  that  have  heen  employed  previously  and  indiscriminately  in  private 
houses,  homes,  or  in  hospitals ;  and  with  a  startling  indifference  (in  the  post- 
operative dressing  of  cases)  to  the  preparation  of  their  hands  and  the  possi- 
bility of  conveying  infection  from  septic  cases  that  thej'^  m&y  have  at  the 
time  been  attending  to.  (The  best  nail-brush  is  that  which  is  screwed  on  to 
the  glass  lid  of  the  glass  box  in  which  it  is  contained.)  Worse  still  is  their 
tendency  to  use  the  first  towel  or  instrument  that  comes  to  hand,  pleasantly 
oblivious  as  to  its  previous  effective  sterilization. 

(7)  Failui'e  may  be  consequent  upon  imperfectly  sterilized  sponges, 
gauze  compresses,  or  dabs  ;  or,  even  if  these  have  been  made  sterile, 
by  their  being  brought  in    contact  with  any  source  of  infection, 


ASEPSIS  AX/>  AxnsEPsrs  IX  arXyECOLOH/CAn  SUHaKHV.    13:; 

either  through  the  hand  of  a  nurse  or  assistant,  or  by  careless  re-use 
when  they  have  been  infected. 

(8)  Failure  arising  out  of  infected  instriDiicnts  is  not  likely  to 
occur  with  any  care,  if  they  be  sterilized  by  means  of  the  dry  stove, 
and  are  of  such  a  kind  that  they  can  have  their  blades  and  handles 
easily  detached,  so  that  the  joints  may  be  thoroughly  subjected  to 
the  necessary  heat.  Danger  more  frequently  arises  from  the  use  of 
instruments  infected  during  the  operation,  and  which  are  not  re-sierilized 
at  the  time.  This  is  perhaps  best  obviated  by  having  always  at 
hand  a  nickel  stove  in  which  the  water  containing  the  sulphide  of 
sodium  is  kept  boiling,  and  into  which  the  suspected  instrument 
can  be  placed  for  some  minutes  before  it  is  again  used.  This 
applies  especially  to  needles  which  have  been  employed  for  suturing 
or  ligaturing  within  the  area  of  infected  tissues.  Hence  the  wisdom 
of  having  always  prepared  for  any  gynjecological  operation  a 
sufficient  supply  of  all  instruments  that  may  possibly  be  called  for, 
as,  in  emergency,  imperfectly  sterilized  instruments  may  be  used,  or 
it  may  not  be  possible  at  the  moment  to  re-sterilize  an  infected 
instrument.  It  is  not  necessary  to  comment  on  the  re-use  of  any 
instrument  or  appliance  which  has  once  fallen  from  the  hand  of  the 
operator. 

(9)  While  the  position  of  Trendelenhurfj  is  invaluable  in  the 
majority  of  pelvic  operations,  it  has  its  dangers  with  regard  to 
asepsis,  from  the  tendency  for  infective  fluids  to  gravitate  from  the 
pelvic  cavity  to  the  bowel,  and  thus  infect  the  latter.  Therefore, 
in  such  cases,  the  large  flat  natural  sponges  come  in  of  use  in 
protecting  the  bowel,  and  the  extreme  Trendelenburg  position 
should  be  avoided.  Judicious  irrigation,  with  sterilized  saline 
solution,  followed  by  careful  drying  of  any  cavity,  and  of  the 
irrigated  parts,  with  gauze  tampons  or  sponges,  is  the  best  means 
that  we  can  adopt.  If  there  be  a  fear  of  post-operative  hsemorrhage, 
the  iodoform  gauze  compress  of  Mikulicz,  pressed  down  into  the 
dried  cavity,  aflbrds  us  the  greatest  security. 

(10)  When  an  operation  is  completed,  and  the  hsemostasis  is 
assured,  and  drainage  if  necessary  provided,  there  are  still  remain- 
ing some  most  dangerous  loopholes  for  sources  of  infection.  These 
are  to  be  found  in  the  abdominal  or  vaginal  toilet.  The  use  of 
infected  needles,  imperfect  sterilization  of  silk  or  catgut,  as  well  as 
in  the  dressings  of  the  wound,  may  furnish  these,  for  instance, 
needles  that  have  been  used  for  suturing  or  ligaturing  infected 
parts ;  or  the   handling  of  gut   or  silk,  for  neither  should  ever  be 


I 


134 


DISEASES   OF   WOMEN. 


handled  after  sterilization,  and  should  reach  the  wound  only  through 
sterilized  forceps  or  scissors.  In  like  manner  the  sterilized  dressing 
for  the  wound,  after  the  latter  has  been  washed  with  1  in  1000  of 
formalin,  and  dried,  should  be  laid  over  it  direct  from  the  jar  or 
bottle  in  which  it  has  been  sterilized  or  hermetically  kept,  and  the 
same  remark  applies  to  the  superficial  sterilized  wool  covering. 
During  any  aseptic  operation,  there  should  be  close  at  hand  to  the 
operator  either  a  lavabo  with  tap  or  a  basin  with  sterilized  water 
and  lysol  or  lysoform,  renewed  from  time  to  time,  in  which  the 
hands  can  be  rinsed  ;  and  after  dealing  with  infected  parts,  or  in  any 
combined  operation  when  passing  from  the  vagina  to  the  abdomen, 
re-sterilization  of  the  hands  should  be  practised  before  again 
proceeding  with  the  operation.  It  is  a  good  plan  to  dust  the 
surface  of  the  closed  wound  with  dermatol,  which  is  readily  steriliz- 
able,  and  is  not  irritating.  I  generally  prefer,  however,  the  washing 
of  the  surface  of  the  skin  with  formalin,  and  then  the  application 
of  the  sterilized  iodoform  gauze. 

Colsetin. — The  area  of  the  wound  may  be  hermetically  covered 
with  colsetin.  This  is  a  fine  adhesive  material  coated  with  zinc 
and  lead.  It  is  very  adhesive.  Under  it  a  joad  of  iodoform  gauze 
is  placed. 

Closure  of  the  wound. — After  careful  readjustment  of  disturbed 
parts,  such  as  the  bowel  and  omentum,  and  having  seen  that 
the  appendix  is  normal  and  in  position,  three  deep  sutures  are 
carried  through  all  the  tissues  with  a  Zweifel's  needle  from  one 

side  to  the  other,  with  the  excep- 
tion of  the  skin.  These  are  long, 
and  are  allowed  to  drop  at  the 
sides,  secured  by  forceps.  These 
deep  through-and-through  sutures  are 
only  used  if  the  wound  he  large.  Next 
the  peritoneum  is  closed  by  fine  con- 
tinuous sutures  of  cumol  gut.  Then 
the  rectal  fascia  is  freely  separated 
with  the  handle  of  a  scalpel,  or  the 
finger-nail,  at  either  side  from  the 
muscle.  The  fascia  is  then  made  to 
overlap  by  continuous  or  interrupted 
suture  of  sterilized  gut,  cumol  or 
other.  In  passing  this  suture  a  portion  of  the  rectus  muscle  at  either 
side  is  included.     Lastly,  the  skin  is  closed  by  a  continuous  suture 


Fig.  106. — Catheter  Sterilizek. 


ASEPSIS  AXD  AXnSEPSIS  7iV  GYNAECOLOGICAL   SURGERY.     135 


of  bronze  aluminium  wire,  celloidinzwirn,  or  interrupted  suture  of 
silkworm  gut.  The  closed  wound  is  now  sponged  with  formalin 
solution,  and  dried.  It  is  next  covered  with  a  few  layers  of 
sterilized  iodoform  gauze,  over  which  is  placed  a  layer  of  coljetin, 
which  reaches  from  the  umbilicus  to  the  groin,  and  is  about  ten 
inches  wide.  This,  properly  trimmed  at  the  groin,  makes  an 
impermeable  covering.  Over  this  is  placed 
a  light  layer  of  sterilized  wool,  and  over  all 
is  drawn  a  tailed  domette  binder. 

Drainage, — Should  septic  comiDlications  be 
present,  such  as  abscesses,  ruptured  pus  sacs, 
pockets  of  septic  pus,  decomposing  tissues, 
or  bowel  contamination,  we  have  in  irrigation 
with  formalin  solution  and  sterilized  water, 
eflective  mopping  out  of  any  cavities  in  which 
septic  material  may  have  collected,  and  the 
iodoform  drain,  whether  abdominal  or  vaginal, 
the  best  means  of  combating  septic  conse- 
quences. 

With  regard  to  the  disputed  question  of 
drainage,  it  will  be  generally  agreed  that  it 

is  safer  to  drain  in  any  of  the  following  Fig.  107.— Metal  Basket 
circumstances  :  (a)  When  pus  has  escaped 
into  the  peritoneal  cavity.  (&)  When  there 
has  been  considerable  hsemorrhage  difl&cult  to 
arrest,  and  in  which  it  has  been  necessary  to 
use  the  aseptic  tampon  to  restrain  it,  and 
when  there  is  the  consequent  danger  of  the 
formation  of  clots,  (c)  In  the  presence  of 
septic  complications,  where  there  has  been 
an  escape  of  septic  fluids,  and,  as  is  frequently  the  case  in  such 
instances,  where  extensive  adhesions  have  necessitated  prolonged 
stripping  of  tumours  or  sacs,  with  more  tedious  manipulation,  (d) 
Drainage  is  indicated  in  certain  cases  of  enucleation  of  myomata 
— in  pan-hysterectomy  for  myoma,  when  there  is  the  complication 
of  pus  tubes,  or  suppurating  cysts  of  the  ovary ;  when  there  has 
been  ha?mato-salpinx  or  a  blood  cyst  of  the  ovary  or  meso-salpinx 
which  may  have  been  ruptured  ;  in  pan-hysterectomy  for  cancer  ;  in 
some  cases  of  supravaginal  hysterectomy,  with  complications  similar 
to  those  just  mentioned,  and  where  we  are  in  doubt  as  to  the 
infectivity  of  the  cervical  stump  and  canal.     Here  the  plan  may  be 


WITH 

Cover. 


Pedal  -  actixg 


There  is  an  inside  metal 
lining,  wliicli  is  taken 
straight  from  the  steri- 
lizer and  placed  in  the 
basket.  The  latter  is 
then  locked  until  re- 
quired for  operation. 


136  DISEASES   OF   WOMEX. 

adopted  of  dividing  the  cervix,  covering  each  separate  pedicle  with 
peritoneum,  and  passing  the  iodoform  drain  between  the  two ;  in 
sanguineous  and  suppurative  ovarian  cystomata ;  in  colloid  multi- 
lociQar  cystoma  in  which  there  is  ascites  present,  and  where  there 
has  ])een  rupture  of  the  cysts  with  escape  of  the  contents  into  the 
peritoneal  cavity. 

(e)  Drainage  is  necessary  in  colpotomy  performed  for  pyo-  or 
hydro-salpiax,  hsematocele,  and  other  cases  of  ectopic  gestation,  and 
in  suppurating  cysts  of  the  ovary,  or  meso-salpinx.  (/)  Drainage 
is  indicated  in  vaginal  operations  and  in  cceliotomy,  when  there 
have  been  wounds  of  the  bladder  or  bowel.  Some  may  think  that 
drainage  is  not  necessary  in  a  few  of  the  conditions  here  mentioned, 
but  I  believe,  with  a  view  to  asepsis,  that  temporary  use  of  di'ainage 
under  all  these  circumstances  is  better  than  the  risk  run  by  imme- 
diate closure  of  the  wound.  Sterilized  iodoform  gauze  generally 
makes  the  best  drain.  If  we  drain  by  means  of  a  tube,  it  should 
be  taken  straight  from  the  carbolic  immersion  fluid,  having  been 
previously  treated  by  boiling  in  a  5  per  cent,  solution  of  perman- 
ganate of  potash,  decolorized  by  bisulphide  of  sodium,  and  after- 
wards boiled  in  distilled  water. 

Catheters. — Two  glass  catheters  should  be  in  use  in  every  case 
where  the  catheter  is  required.  They  should  be  sterilized  after  use, 
in  a  catheter  sterilizer,  and  then  placed  in  a  1  per  cent,  solution 
of  formalin.     If  a   sterilizer  be   not  at  hand,  the  catheter  should 


Fig.  108. — Glai^s  Cathetek. 

be  boiled  and  kept  in  a  5  per  cent,  carbolic  or  formalin  solution 
until  it  is  required.  Thus  a  freshly  sterilized  instrument  is  used 
each  time. 

Subsequent  Dressings. — In  many  cases,  for  some  days  it  is 
unnecessary  to  change  the  dressing  when  all  is  progressing  satis- 
factorily. When  any  dressing  is  about  to  be  conducted,  the  hands, 
both  of  surgeon  and  nurse,  should  be  rendered  aseptic.  All  dress- 
ings shoidd  be  in  readiness  and  close  by  the  patient,  while  the 
wound  is  exposed  for  as  short  a  time  as  possible.  The  same  remark 
applies  to  the  removal  of  the  skin  sutures.  I  invariably  use 
sterilized  gauze,  wet  with  a  1  per  cent,  formalin  solution,   to  lay 


PLATE    X. 


Steeptococcus  Pyogenes 
(1  X  1000). 


Goxococcus  (Neissee) 
(1  X  1000). 


Staphylococcus  Pyogenes 
(1  X  1000). 


B.  CoLi  CoiJMrNis 
(1  X  1000). 


B.    TCBERCTJLOSIS    (1  X  1000). 


[To  face  p.  137. 


ASEI'SL^  AM)   Ayr/SEfsfS   IX   GYNJECOLOOICAL   SUItOEIiY.     137 

t>ver  the  wound  immediately  it  is  exposed,  while  the  new  dressings 
are  being  applied,  the  iodoform  and  gauze  tampon  or  drain  being 
removed  after  forty-eight  hours. 

Bacteriology. 

More  than  a  brief  reference  to  the  Ijacteriology  of  the  female 
organs  of  generation  is  not  possible,  nor  indeed  would  any  lengthy 
description  be  desirable,  as  in  the  many  admirable  works  on  this 
subject,  and  in  the  bacteriological  laboratory  by  practical  investiga- 
tion, the  student  or  practitioner  alone  can  hope  to  obtain  a  clear 
and  comprehensive  mastery  of  the  subject.  But  as  in  dealing  with 
various  inflammatory  processes  it  will  be  necessary  to  refer  by  name 
to  certain  micro-organisms  which  are  associated  with  them,  and 
more  particularly  with  those  of  a  septicsemic  nature,  it  may  be 
well  here  to  particularize  those  organisms  which  have  more  special 
influence  on  gynaecological  surgery  and  practice. 

1.  Ddderlein's  Bacillus. — It  is  now  well  known  that  Doderlein  attributed  a 
bactericidal  influence  to  the  vaginal  secretion  as  long  as  it  remained  acid, 
which  is  its  normal  condition,  and  further,  that  this  healthful  influence  was 
to  be  ascribed  to  an  anaerobic  bacfllus  which  was  easily  cultivated  on  almost 
any  media  at  37°  C.  with  2  per  cent,  of  glucose,  or  in  hydrogen.  Kroenig 
and  Menge,  however,  described  anaerobic  non-pathogenic  bacilli,  which  exist 
in  the  vagina  and  in  its  normal  acid  secretion,  and  are  destructive  of  the 
pathogenic  organisms.  Their  experiments  would  lead  to  the  conclusion  that 
in  the  vagina,  with  an  unabraded  mucus  surface,  we  have,  in  its  normal  acid 
secretion,  and  in  the  naturally  closed  state,  reliable  germicidal  forces  at  work. 
Taking  these  facts  into  consideration,  with  that  of  the  closed  canal  of  the 
cervix  through  its  mucus,  we  see  the  provision  made  by  nature  against  septi- 
csemic  processes  in  the  genital  tract. 

2.  Staphylococcus  Pyogenes  Aureus, — This  micro-organism  is  frequently 
fovmd  in  suppurative  discharges,  aud  is  perhaps  most  commonly  met  with. 
It  is  generally  found  associated  with  other  bacteria  of  the  same  group,  and  is 
more  vu-ulent  than  the  staphylococcus  pyogenes  albus,  or  citreus.  The 
staphylococcus  pj'ogenes  aureus  occurs  in  masses  of  cocci  in  groups,  more 
rarely  singly,  or  in  short  chains. 

3.  Streptococcus  Pyogenes. — The  streptococci  is  another  most  viriflent 
organism,  its  name  being  familiar  to  surgeons  as  associated  with  erysipelatous 
inflammation,  peritonitis,  and  puerperal  septicaemia.  The  cell  elements  of 
the  streptococci  are  larger  than  those  of  the  staphylococci,  and  occur  in 
chains,  either  in  groups  or  in  single  rows  ;  and  it  would  appear,  from  experi- 
ments such  as  those  of  Marmorek  and  others,  that  the  relative  virulence  of 
this  organism  may  be  due  to  its  method  of  cultivation.  It  does  not  appear 
that  bacteriologists  have  as  yet  satisfied  themselves  as  to  the  various  causes 
Avhich  influence  the  difierent  forms  of  staphylococci  and  streptococci  in  their 


138  DISEASES    OF   W02IEX. 

comparative  and  relative  degi'ees  of  viiTdence.  The  practical  surgeon  is  ever 
mindful  of  the  fact  that  where  suppurative  and  septicsemic  processes  aiise 
and  spread,  such  origin  and  dLssemination  are  found  associated  with  their 
presence.  He  has  also  to  realize  that  the  danger  arises  from  an  inappreciable 
quantit}'  of  the  infective  material.  A  few  germs  are  sufficient  to  produce 
the  mischief  and  bring  about  such  pathogenic  conditions  as  will  destroy  life. 
It  is  many  years  since  Koch  showed  that  a  trillionth  part  of  a  drop  of  dried 
septicaemic  blood,  taken  from  a  mouse  infected  with  anthrax,  and  preserved 
hermetically  for  a  considerable  time^  was  sufficient,  when  in  solution,  to  pro- 
duce septicsemia  in  a  healthy  mouse.  What  amount  of  poison,  then,  a 
surgeon  may  carry  in  the  handy  receptacle  of  an  unpared  nail,  those  who 
would  differentiate  for  us  between  the  '•  grosser  "  and  "  lesser  "  degrees  of 
septic  material  on  tlie  hands  or  person  of  an  operator  can  best  compute. 

4.  Tubercle  Bacilli. — Xow  that  primary  tubercle  of  the  uterus,  Fallopian 
tube,  and  oyary  has  been  proved  to  occur,  and  that  tubercular  disease  has 
been  shown  frequently  to  invade  both  the  uterus  and  adnesa,  the  isolation  of 
the  tubercle  bacillus,  and  its  recognition  in  the  genital  tract,  is  of  supreme 
importance  to  the  gynaecologist.  This  will  have  to  be  referred  to  several 
times  in  dealing  with  the  question  of  tuberculosis.  The  morphological 
features  of  the  tubercle  bacillus  are  weU  known. 

5.  Micrococcus  Gonorrhcea,  or  the  Gonococcus  of  Neisser. — It  is  essential 
that  every  practitioner  should  know  the  characteristics  of  this  organism.  In 
shape  it  has  been  described  as  like  two  buns  with  then  flat  bases  facing  each 
other ;  but  this  arrangement  of  pairs,  in  double  chain  or  otherwise,  is  not 
characteristic  of  this  diplococcus,  for  others  occur  of  the  same  shape  in 
healthy  vaginal  mucus  and  in  the  lochia.  Its  occurrence  in  a  purulent  dis- 
charge, in  such  gi'oups  or  colonies,  lying  free  hetvjeeii  the  ]jus  cells,  or  lodged 
vntldn  the  pus  cell  itself,  is  its  most  characteristic  feature.  It  does  not  stain 
by  Gram's  method.  It  requires  a  fresh  blood  medium,  and  a  temperature  of 
the  blood,  to  grow.  If  the  gonorrhceal  pus  be  mixed  with  uncoagulated 
serum,  and  the  mixture  be  added  to  two  paiis  of  melted  agar,  at  a  tempera- 
ture of  40°  to  45°  C,  and  this  be  then  allowed  to  solidify  obliquely  in  the 
tube,  the  gonococcus  wiU  be  cultivated.*  Xewman  states  that  it  is  possible 
to  sub-culture  on  ordinary  media  from  such  cultures.  Other  methods 
have  been  recommended,  and  will  be  found  in  text-books  on  bacteriology. 
The  lower  animals  do  not  take  this  disease  by  inoculation.  The  relation  of 
the  gonococcus  to  pyo-salpinx,  and  the  association  of  gonorrhoeal  infection 
with  sj'philis,  and  the  relation  of  both  to  pelvic  inflammation,  will  be  referred 
to  when  we  are  dealing  with  these  latter. 

Bacillus  Coli  Communis. — This  bacUlus  is,  as  Hewlett  observes,  one  of  the 
most  widely  distributed  organisms  in  nature,  being  aerobic,  and  facultative 
anaerobic.  It  is  a  short  rod  with  rounded  ends  2  or  3  millimetres  long,  and 
0'4  to  0*6  millimetres  broad,  frequently  linked  in  pairs  or  more.  It  varies 
somewhat  in  size  and  shape,  is  feebly  motile,  and  possesses  lateral  flagellae  to 
the  number  of  from  two  to  ten.  It  occurs  commonly  in  the  intestinal  tract 
of  men  and  animals  (Hewlett).  It  can  be  readily  isolated  and  cultivated 
from  faeces.     It  is  known  by  several  distinguishing  morphological  and  culture 

*  British  Gynmcologicol  Jo'irnal,  May,  1898. 


ASEPSIS  AND  ANTISEPSIS  IN  GTNJECOLOGICAL   SURGERY.     139 

peculiarities  from  the  bacillus  typhosus.  Pathogenic  in  its  action,  it  causes 
death  when  introduced  into  the  circulation  in  variable  periods  of  time,  and 
has  a  toxaimic  ertoct  wlien  introduced  into  the  peritoneal  cavity.  Its  chief 
interest  to  the  gynaecologist  lies  in  the  fact  that  it  is  the  organism  of  which 
he  is  most  fearful  as  the  cause  of  peritonitis  when  there  has  been  any  bowel 
infection,  either  primarily  through  traumatic  causes  in  operation,  or  secon- 
darily from  infection  from  the  contiguous  intestine  in  suppurative  pelvic 
states  demanding  operation,  which  are  apt  to  involve  the  rectum  on  the  one 
side,  or  the  appendix  on  the  other.  The  most  important  pathological  point 
is  that  the  bacillus  may  find  its  way  through  the  intestinal  tunics  when  these 
have  been  injured,  but  not  perforated. 

Found  likewise  in  the  lungs  and  pleural  cavities,  it  may  explain  those 
cases  of  septic  pleuro-pueumonia  which  occur  occasionally  as  sequelae  of 
pelvic  and  intestinal  operations. 

Stroganoff  still  maintains  that  the  cervix  of  both  pregnant  and  unpregnant 
healthy  women  does  not  usually  contain  microbes — that  the  region  of  the 
external  os  defines  the  boundary  between  the  microbe-bearing  and  non- 
bearing  regions,  and  that  the  cervical  mucus  destroys  microbes. 

Fuerbringer  and  Freyhau  *  have  repeated  the  experiments  of  Ahlfeld, 
Reinicke,  and  Poten,  and  have  come  to  the  conclusion  that  the  bactericidal 
property  of  alcohol  in  combination  with  corrosive  sublimate  is  due  to  the 
removal  of  the  fat  from  the  skin  of  the  hands,  while  its  power  of  uniting  with 
water  renders  disinfection  of  the  tissues  easy  by  the  associated  sublimate,  or 
its  subsequent  solution,  at  the  same  time  that  the  squamous  epithelium  and 
the  superficial  impurities,  as  well  as  the  bacilli,  are  removed. 

Micro-organisms  in  the  Endometrium. 

Ernest  Laplace,  Philadelphia,  as  the  result  of  a  series  of  important  expe- 
riments in  Koch's  laboratory,  says,  '  These  experiments  proved  that  in  the 
normal  endometrium  numerous  organisms  were  present,  which  do  not  w^ant 
any  air,  inasmuch  as  they  are  quite  on  the  surface.  In  endocervicitis  the 
Streptococcus,  Pyogenes  Aureus,  Alius,  and  Citreus,  with  Bacillus  Pyocy- 
aneus,  were  found. 

'  The  results  of  the  experiments  proved  : — 

'1.  The  normal  endometrium  of  uterus  and  cervix  is  a  harbour  for  vast 
numbers  of  micro-organisms,  most  of  which  are  known  to  us,  but  some  still 
unknown,  and  possessing  poisonous  qualities  for  guinea-pigs. 

'  2.  The  inflamed  endometrium  contains  the  same  kinds  of  micro-organisms, 
but  in  vaster  quantities,  the  superficial  exfoliating  cells  also  containing  them. 

'  3.  In  chronic  endometritis  the  secretions  contain  about  as  many  infec- 
tious organisms,  the  mucous  membrane  and  fibrous  tissue  becoming  greatly 
hypertrophied  under  the  continued  development  of  these  organisms,  and 
whether  this  chronic  condition  be  simple  or  gonorrhceal,  we  find  the  germs 
both  in  the  epithelium  and  fibrous  tissue. 

'  It  now  becomes  necessary  to  explain  how  these  organisms  get  to  the  deeper 
parts,  and  how  far  their  relations  as  a  cause  of  the  inflammation  extend. 

*  '  Deutsche  Med,  Woschen,'  1897. 


140  DISEASES   OF   WOMEN. 

'  It  is  plain  that  the  mere  presence  of  the  micro-organisms  does  not  suffice 
to  constitute  disease.  Disease  is  the  reaction  upon  the  system — local  or  general, 
or  both — resulting  from  the  developing  organism.  In  the  uterus  the  normal 
secretions  ai'e  a  2^oor  culture  medium  for  germ  life,  and  at  the  same  time 
keep  the  micro-organisms  at  a  distance  from  the  blood-vessels.  If  given  the 
proper  opportunity,  however,  and  furnished  with  blood  or  serum  retained  any 
undue  length  of  time  within  the  uterine  cavity,  micro-organisms  develop 
therein  with  as  remarkable  rapiditj'  as  they  do  upon  artificial  culture  media 
in  the  laboratory.  Now  the  conditions  will  have  changed,  and  enormous 
hordes  of  bacteria  soon  develop  from  those  already  present,  and  infect  the 
tissues.  Judging  from  the  reaction  of  tissues  under  the  influence  of  de- 
veloping bacteria  elsewhere,  we  should  say  that  cold  is,  perhaps,  the  most 
frequent  cause  of  the  initial  process ;  the  congestion  which  soon  follows  the 
action  of  cold  upon  the  tissues  being  familiar  to  us  all.  Next  follows  the 
exudation  of  serum,  which  is  soon  contaminated  by  the  bacteria  in  the  neigh- 
bourhood ;  these  finding  their  most  favourable  soil  develop  rapidly,  producing- 
a  chemical  irritant  or  ptomaine  which  is  the  decomposition  of  the  serum 
incident  to  their  growth ;  this  acts  as  a  direct  chemical  irritant  which  keeps 
up  indefinitely  the  irritated  condition  of  congestion,  and  hence  hj'pernutrition 
of  superficial  cells,  proliferation  of  cells  resulting,  which  cells  naturally  find 
their  protoplasm  inoculated  from  the  first  with  the  bacteria  under  whose 
impulse  they  developed. 

'  In  the  chronic  fomi,  with  hyperplasia  of  fibrous  tissue,  there  seems  no 
explanation  save  that  the  original  infection  took  place  as  above  described, 
and  that,  either  from  neglect  or  other  causes,  the  parts  have  become  so 
irritated  that  the  deeper  fibrous  tissue,  imder  constant  congestion,  became 
infiltrated  -with  white  blood  corpuscles  by  diapedesis,  which  gradually  built 
new  fibrous  tissue,  dovetailing  with  that  already  existing. 

'  Simply  from  a  histological  and  pathological  standpoint,  inasmuch  as  the 
foundation  of  treatment  in  disease  is  the  removal  of  the  cause,  finding  that 
these  micro-organisms  exist  nearly  always  to  a  certain  depth,  curetting  is  the 
rational  treatment — removal  of  all  the  diseased  cells  through  which  we  could 
not  expect  an  antiseptic  to  act.  Thorough  scraping  being  done,  it  but 
remains  to  so  sterilize  the  regenerating  mucous  membrane  as  to  leave  it  un- 
contaminated.  Here  the  acid  sublimate  solution  finds  a  happy  application  in 
the  strength  of  1  in  2000  to  1  in  5000.'  *  ^ 

Eichelot  emphasizes  the  fact  that,  side  by  side  with  any  aseptic  or  anti- 
septic methods,  there  must  be  complete  technique  on  the  part  of  the  surgeon 
and  those  engaged  in  the  operation,  exact  hsemostasis,  and  complete  anaesthesia. 
The  longer  the  operation  the  greater  the  chance  of  infection ;  but,  he  is  care- 
ful to  add,  rapidity  of  execution  should  not  supersede  prudence  in  operation. 
A  bungling  operative  procedure  may  neutralize  our  aseptic  precautions.  The 
more  the  vitality  of  our  patient  is  interfered  with  by  disease,  the  greater  need 
there. is  for  dexterity  of  execution  and  attention  to  detail  in  operation.  The 
continual  effort,  says  Eichelot,  to  perfect  asepsis,  'has  developed  the  most 
admirable  results.'  If  we  cannot  destroy  the  existence  of  bacteria,  we  may 
at  least  prevent  ourselves  from  carrying  infection  to  our  patient. 

*  American  Journal  of  Medical  Science,  Oct.,  1892. 


ASEPSIS  AM)  Ayr/SEPS/s  j\  ny.yjECOLOiiiCAL  sriiOEjn:    141 


The  Peritoneum. — We  may  take  it  that  tlie  peritoneum  is  endowed  by 
bactericidal  qualities  whii-h  are  increased  in  direct  ratio  to  its  power  of  al)8orp- 
tion.  Irritation  of  the  peritoneum  by  chemicals  predisposes  to  peritonitis  and 
sepsis,  as  also  do<s  the  presenee  of  stagnant  fluid  or  a  blood-clot  in  the  peritoneal 
cavity.  Ascites  predisposes  to  peritonitis  and  sepsis  by  the  prevention  of 
absorption,  and  by  the  cultun-  medium  which  the  ascitic  fluid  furnishes. 

Kelly  lays  emphasis  on  tlie  investieations  of  Muscatello  (  FircAoic's  XrcAt r  , 
189.5),  which  show  that  an  intra-peritoneal  current  carries  fluids  and  small  par- 
ticles towards  the  diaphragm,  and  that  the  rapidity  or  otherwise  of  the  current  is 
influenced  by  gravity.  Such  particles  pass  through  the  lymph  spaces  of  the 
diaphragm  and  thence  into  the  lymphatic  vessels  and  glands,  from  whence  they 
reach  the  blood. 

From  the-  blood  such  solid  particles  arc  deposited  in  the  collecting  glands  of 
each  organ.  Kelly,  from  Muscatello"a  experiments,  regards  the  elevated  posture 
us  a  prophylactic  against  peritonitis.  This  fact,  as  we  show  elsewhere,  also 
bears  on  the  post-operative  treatment  of  abdominal  coeliotomy. 

The  Saliva  of  the  Operator  a  Source  of  Infection. — Mendes  de  Leon,  in 
a  recent  communication,*  showed  by  conclusive  experiments  that  small 
particles  of  salivan-  secretion  were  emitted  from  the  mouth  of  the  operator 
in  ordinary  speech.  Such  fine  particles  contained  streptococci  and  staphylo- 
cocci— hence  the  danger  arising  from  the  operator  speaking  directly  over  a 
wound  during  operation.  This  is  met  in  some  clinics  by  the  use  of  masks, 
or,  as  Mendes  de  Leon  suggests,  a  nickel  mouthpiece  like  an  inhaler  con- 
tainin?  cotton  wool. 


Figs.  108a,  V)Sb. — Aseptic  Mask  of  ArxHOB. 

It  consists  of  two  naso-oral  pieces.  Tlie  inside  is  removable  so  as  to  permit  of 
sterilized  gauze  being  inserted.  It  is  very  light,  and  in  no  way  interferes 
with  speech  or  respiration.  It  can  also  be  had  with  an  occipito-frontal 
spring. 


Brit.  Gyn..  Soc,  .Jau.,  1904. 


CHAPTER  V. 

SOME   MINOR    GYNiECOLOGICAL    OPERATIONS. 

Applying  Nitric  Acid  to  the  Cavity  of  the  Uterus. — This  is  a 
simple  step  that  any  intelligent  practitioner  should  be  able  to  take 
in  chronic  cases  of  endometritis  and  subinvolution  which  must 
occasionally  come  under  his  care.  When  efficiently  carried  out,  it 
is  a  safe  therapeutical  measure.  Of  recent  years,  however,  I  prefer 
curettage  and  the  application  of  chromic  acid. 

It  is  a  step  which  should  be  avoided  immediately  before  or  after 
a  period.  It  is  well  also  in  all  operations  on  the  uterus  or  ovaries 
to  secure  such  mental  rest  and  quiet  as  we  can,  and  to  subdue  any 
morbid  excitement  of  the  nervous  system  generally.  For  this  purpose 
bromide  of  ammonium  or  bromide  of  potassium  may  be  given  for  a 
few  nights  before  operating.  The  secretions  should  be  seen  to,  and 
the  rectum,  if  necessary,  emptied  by  an  enema  on  the  morning  of 
any  operative  interference. 

The  uterine  canal  having  been  previously  dilated,  the  instruments 
we  require  are — a  duck-bill  speculum,  a  few  uterine  wool-holders, 
and  retractors.  We  have  also  fuming  nitric  acid,  vaseline,  glycerine, 
and  some  absorbent  cotton-wool  at  hand.  An  assistant  or  nurse  is 
indispensable. 

The  woman  is  placed  in  the  semi-prone  or  lithotomy  position,  and 
brought  well  to  the  edge  of  the  tabl"e  opposite  a  good  light,  Sims'^ 
speculum  is  introduced,  and  the  uterus  is  steadied  and  drawn  well 
into  view  ivith  a  liooh  or  tenaculum.  A  thin  layer  of  cotton-wool 
has  previously  been  rolled  tightly  round  one  of  the  platinum  probes 
to  the  extent  of  about  two  inches.  The  sides  of  the  vagina  and  the 
vulva  are  carefully  protected,  and  are  drawn  to  either  side  with 
retractors.  Any  bleeding  that  may  occur  having  been  arrested,  the 
probe  is  now  dij)ped  lightly  in  the  acid,  and  it  is  a  good  plan  to  roll 
it  on  the  side  of  the  slice  so  as  to  press  out  any  suj^erfluous  moisture. 
It  is  then  carried  to  the  fundus,  and  cautiously  withdrawn  so  as- 
not  to  touch  the  soft  parts. 


so^fl:  Mfxon  gykjeco logical  opEBAnoNS. 


143 


If  the  uterine  canal  be  thoroughly  dilated  and  dried,  the  use  of 
an  intra-uterine  cannula,  such  as  that  of  Atthill,  may  be  dispensed 
with.     A  second  uterine  probe  is  ready  charged  with  some  vaseline 


Fig.  109. — Exact  Size  of  Holdku  covered  ■with  the  Wool. 

which  it  is  well  to  pass  after  the  acid  has  been  applied  to  the  fundus 
uteri.     It    helps    to    prevent   adhesions.     A  tampon  of    moistened 


Fig.  110. — Roughened  Exd  of  Wool-holdeh. 


iodoform  gauze  is  placed  in  the  vagina.     The  patient  should  remain 
in  bed  and  have  the  vagina  dressed  each  day ;  any  discharge  must 


Fig.  111. — Hall's  Laxcet. 


be  carefully  wiped  away,  and  a  fresh  tami^on  placed  in  the  vagina. 
These  same  directions  apply  to  the  use  of  a  strong  chromic  acid 
solution. 

Depletion  of  the  Cervix  Uteri. — For  this  purpose  the  cervix  uteri 
is  exposed  with  a  good-sized  tubular  sjjeculum,  the  patient  lying  on 
her  back.  With  a  Hall's  lancet  (a  set  of  difterent  sizes  in  a 
small  case  may  be  had)  some  punctures,  according  to  the  quantity 
of  blood  we  require  to  take,  are  made  in  the  cervix  and  the  neigh- 
bourhood of  the  OS  uteri.  A  speculum  slice  is  slipped  under  the  lip 
of  the  speculum,  and  the  blood  is  permitted  to  run  into  it.  I  belieA'e 
rather  in  occasional  depletion  than  in  the  abstraction  of  a  large 
quantity  of  blood  at  one  time.  It  is  better  not  to  make  these 
punctures  too  freely.  Otherwise,  and  in  the  absence  of  efficient  tam- 
poning, awkward  bleeding  may  occur,  and  serious  syncope  follow. 

When  sufficient  blood  has  been  drawn,  it  is  easy  to  stop  any 
further  loss  by  plugs  of  dry  wool  pressed  up  through  the  speculum 


141 


DISEASES   OF   WOMEN. 


against  the  cervix  uteri.  The  vagina  is  tamponed  temporarily 
with  some  gauze.  It  is  well  to  deplete,  especially  in  a  case  of  con- 
gestive dysmenorrhcea,  shortly  before  the  advent,  of  a  period. 

Aspiration. — When  an  aspirator  is  used  for  therapeutical  purposes, 
I  prefer  the  larger  needles,  as  shown  in  Fig.  74.  The  aspirator  I 
have  been  using  for  years,  and  which  I  have  found  most  convenient, 
is  that  of  Matthews  (Fig.  73).  The  needle-points  are  protected  after 
insertion  by  a  cannula ;  the  piston  also  completely  prevents  the 
admission  of  air. 

The  Actual  Cautery. — There  is  no  appliance  to  surpass  for  general 
use  the  benzoline  cautery  of  Paquelin.  It  is  available  also  for 
cutting  purposes,  growths,  small  tumours,  vascular  excrescences, 
malignant  disease  of  the  uterus,  amputation  of  the  cervical  neck, 
perforation  of  a  filDroid  tumour  of    the  uterus,  and   haemorrhoids. 


Fig.  112. — Sattler-Niedex  Universal  Cautery  Handle,  with  Snare. 

For  very  small  tumours  and  for  operation  on  the  urethra,  the 
galvano-cautery  answers  admirably.  Fine  platinum  points  can  be 
obtained  of  any  shape.  All  instrument-makers  now  furnish  portable 
cautery  batteries.  Porcelain  cautery  points  can  also  be  ha.d  if 
required. 


Fig.  113. — Porcelain  Cautery. 


Division  of  the  Cervix  alone.—  If  the  cervical  canal  has  to  be  cut 
the  only  operation  that  affords  any  permanent  relief  is  that  in 
which  the  internal  os  is  also  divided.  It  must  be  remembered  that 
even  with  this  simple  step  it  is  necessary  to  adopt  every  aseptic 
precaution.  The  rectum  is  cleared  before  operation,  and  the  vagina 
carefully  sterilized.  The  dorsal  position  is  chosen ;  the  uterus  is 
drawn  well  into  view  and  held  by  a  tenaculum.  Klichenmeister's 
scissors  is  used.     One  blade  is  cart'ied  to  the  internal  os,  and  the 


SOME  MINOR   GTXJECOLOOICAL    OPERATIOS.^. 


145 


cervix  is  divided  at  one  side.  This  division  is  repeated  at  the  oppo- 
site side.  This  is  simple  division  of  the  cervix.  It  is  a  step  which, 
taken  alone,  is  seldom  indicated.  The  operator  must  see  thoroughly 
how  far  he  is  cutting,  and  the  extent  of  introduction  of  the  blade. 


Kuchkn-mlister's  Scissoks. 


Division  of  the  Internal  Os.* — In  cases  of  sterility  where  dilatation 
has  failed,  in  severe  endometritis  with  dysmenorrhcea,  and  in 
spasmodic  dysmenorrhcea,  division  of  the  cervix  uteri  and  internal 
OS  is  indicated.  It  must  be  remembered  that  we  are  more  likely 
to  have  haemorrhage  from  the  uterine  vessels  ;  we  are  closer  to.  the 
peritoneum ;  there  is  a  greater  risk  of  metritis,  and  there  is  more 
immediate  shock  to  the  woman.  Every  precaution  taken  in  the 
simpler  operation  is  adopted  in  this.     The  instrument  I  prefer  is 


Fig.  115. — Makiux  Suis'  Knife. 
Blades  (natural  size)  contained  in  tlie  handle. 

a  Sims'  knife.  The  blunt-pointed,  straight,  and  curved  blades  are 
carried  in  the  handle,  and  can  be  adjusted  at  any  angle  to  its  long 
axis.  The  preliminary  steps  are  those  taken  for  division  of  the 
cervix.  The  knife  is  then  passed  through  the  cervix  uteri  and 
internal  os,  the  incisions  being  carried  laterally  or  crucially.  The 
posterior  incision,  with  the  exsection  of  a  small  triangular  portion 
of  the  neck  of  the  uterus,   as  suggested   by   Sims,   has  the   great 

*  This  operation  is  more  fully  referred  to  in  the  cliapter  on  dysmenorrha-a 
and  stenosis. 


146 


DISEASES   OF   WOMEN. 


advantage  that   it  places  the  axis  of   the  patient's  uterine  canal 
in  the  most  favourable  position  for  conception.     This  is  still  more 

apparent  if  there  be  an  ante- 
flexion associated  with  the 
sterility.  After  the  uterine  isth- 
mus is  divided,  a  medium-sized 
dilator  is  passed  into  the  cavity 
of  the  fundus.  Bleeding  is  ar- 
rested by  carrying  small  strips  of 
sterilized  gauze  into  the  cavity, 


Fig.  116. — Author's  Oelluloid-wire 
Stem.*    (Arnold.) 


and  finally,  a  strip  of  sterilized  iodoform  gauze  is  left  in,  and  the 

vagina  tamponed  as  after  curet- 
tage. These  tampons  are  removed 
after  48  hours.  The  only  stems 
I  use,  and  these  seldom,  are  those 
of  glass  as  advised  by  Sims,  or, 
what  I  prefer,  my  celluloid  and 


Fig.  117. — Syphon  Trocar  of 
Sir  Spencer  Wells. 


Fig.  118. — Trocar  and  Cannula  for 
emptying  Large  Cysts  or  for  use  in 
Ovariotomy. 


*  This  can  be  moulded  to  any  shape,  and  by  means  of  a  loop  of  Chinese  silk 
passed  through  a  hole  in  the  short  handle  of  the  stem  it  can  be  readily  with- 
drawn by  the  nurse  or  the  patient  herself. 


SOME  MINOR   GYNECOLOGICAL    OPERATIONS.  147 

wire  stems  (Fig.  116).  Xo  precaution  must  be  omitted,  after  incising 
the  cervix,  against  exertion,  cold,  coitus,  or  septic  contagion.  It  is 
better  to  keep  the  canal  open  with  one  of  the  stems  here  suggested. 
Paracentesis  Abdominis. — This  is  an  operative  measure  sometimes 
demanded — 

(a)  For  purposes  of  diagnosis  (ambiguous  cases)  ; 

(h)   Where  the  operation  of  ovariotomy  is  contra-indicated,  to 
prolong  life ; 

(c)   As  a  palliative  measure,  to  gain  time  in  certain  cases,  and 
to  afford  temporary  relief ; 

{d)  In  some  cases  where  pregnancy  or  ascites  complicates 
ovarian  dropsy. 
It  has  to  be  remembered  that  simple  tapping  of  an  ovarian  cyst 
lias  been  followed  by  death  from  shock,  peritonitis,  the  escape 
of  cyst  contents,  or  blood  escaping  into  the  peritoneal  cavity,  and 
septicaemia.  Therefore  it  is  well,  in  preparing  to  tap,  that  we  should 
decide  beforehand  clearly  with  what  object  the  step  is  taken. 
Barely  is  it  Justified  in  ovarian  cystoma.  If  our  desire  be  to  assist 
the  diagnosis,  then  I  prefer  the  aspirator  (Fig.  73).  The  rod  in  the 
needle  prevents  the  admission  of  air.  Such  a  needle  will  possibly 
empty  even  a  large  cyst.  If  we  have  a  doubt  as  to  the  nature  of  the 
fluid,  while,  at  the  same  time,  we  are  anxious  to  tap  the  cyst,  the 
trocar  of  Spencer  "Wells  is  an  admirable  instrument  (Fig.  117).*  The 
larger  the  bore  of  the  trocar,  the  safer  it  is  in  all  such  cases.  One 
of  the  most  awkward  accidents  of  jsaracentesis  is  the  clogging  of  the 
tube  with  semi-solid  material,  and  the  escape  of  cystic  fluid  as  a 
consequence  into  the  peritoneal  caxdty.  Having  decided  to  tap,  we 
prepare  our  patient  by  attention  to  the  secretions,  giving  a  dose  of 
bromide  of  potassium  on  the  night  preAious  to  the  operation.  Im- 
mediately before  it  the  urine  is  drawn  off  by  an  assistant.  Save  to 
allay  nervousness,  an  anaesthetic  is  not  necessary.  Chlorethyl  spray, 
or,  if  this  is  not  at  hand,  anaesthetic  ether  sprayed  on  the  site  of 
the  small  preliminary  incision,  or  the  application  of  a  lump  of  ice, 
the  end  of  which  has  been  dipped  in  a  little  salt,  will  deaden  the 
sensibility  (Goodell).  It  is  better,  if  possible,  to  select  the  linea 
alba.  It  is  the  exception  when  we  are  compelled  to  make  the  punc- 
ture elsewhere,  through  the  accident  of  some  solid  matter  occupying 
the  position  of  the  median  line.  The  abdomen  haAdng  been 
thoroughly  cleansed,  may  be  embraced  in  a  split  roller.  This  is 
drawn  tighter  as  the  fluid  escapes,  and  it  serves  to  support  the 
*  Also  Kceberle's  trocar,  p.  118. 


148 


DISEASES   OF    WOMEN. 


abdominal  wall  during  the  emptying  of  the  sac  and  the  removal 
of  the  pressure  from  the  great  vessels.  The  woman  is  brought  well 
to  the  edge  of  the  bed,  the  abdomen  projecting  over  it.  A  bucket 
containing  a  little  water  is  at  hand  to  receive  the  contents  of  the 
cyst,  so  that  the  end  of  the  tube  attached  to  the  trocar  may  dip 
below  the  surface,  and  thus  the  admission  of  air  be  prevented.  A 
small  incision  is  now  made  over  the  linea  alba,  in  the  abdominal 


119. — Fine  Aspirating  Trocar  and  Caxxtjla. 


integument,  midway  between  the  pubes  and  umbilicus,  and  the  steri- 
lized trocar  is  plunged  into  the  cyst.  If  it  be  a  poly  cyst,  the  trocar  may 
be  made  to  pierce  the  other  cysts  without  withdrawal.  When  the 
fluid  has  ceased  running,  extra  caution  must  be  exercised  in  pi-event- 
ing  the  admission  of  aii',  or  any  fluid  likely  to  excite  inflammation. 

The  wound  is  closed  with  dry  antiseptic  dressing.     If  the  incision 
should  have  been  made  too  large,  a  silver-wire  suture  should  be  inserted. 


Fig.  120. — Kcebeele's  Teocar  akd  Cannula. 

The  hooks  are  sheathed  when  not  required.     They  serve  to  hold  the  cannula  to 

the  cyst  walls. 

The  prepared  thymol  or  iodoform  pads  will  be  found  most  convenient 
to  lay  over  the  wound  after  all  such  operations.  The  same  care  should 
be  exercised  to  anticipate  peritoneal  inflammation  after  paracentesis 
as  after  the  more  formidable  operations  of  abdominal  section. 

Vaginal  Function.* — It  may  be  necessary  to  remove  fluid  from  a 
cyst,  ovarian  or- other,  by  the  vagina.  A  small  cyst  maybe  localized 
in  the  pelvis,  occupying  Douglas'  space.  In. a  multilocular  cyst  the 
solid  part  may  be  above,  and  the  fluid  cysts  distend  the  lower  portion 

*  Consult  chapter  on  'Perimetritis  and  Pelvic  Suppuration.' 


SOME  MI  son   GYXuECOLOaiCAL    OPERATION.^. 


14y 


of  the  tumour.  All  the  dangers  of  peritonitis  and  septiceemia  are  to  he 
guarded  against  in  vaginal  paracentesis.  The  vagina  has  to  be  pre- 
viously prepared  as  already  described  (chap.  iv.  p.  129),  and  all  in- 
struments used  are  sterilized.  It  is  preferable,  as  a  rule,  to  use  an 
aspirator ;  otherwise,  a  long  curved  rectal  trocar,  or,  still  better,  the 
small  guarded  ovarian  trocar  of  Spencer  Wells,  must  be  chosen, 
with  a  tube  attached,  the  lower  end  of  which  can  pass  into  some 
liuid  in  a  vessel  at  the  side  of  the  bed.  The  most  perfect  instrument 
for  exploring  cyst  cavities  and  pelvic  accumulations  is  the  exploring 
trocar  and  cannula  with  branched  dilator  of  Landau  (Fig,  121).  The 
patient  is  best  placed  in  the  lithotomy  position.  The  rectum  and 
bladder  (as  in  all  operative  procedures  on  the  pelvic  viscera)  are 
first  emptied.  A  careful  and  final  exploitation  of  the  pelvic  organs 
is  made.     The  most  prominent  part  of  the  tumour  is  felt,  where  we 


Fig.  12].— Tr.uCAK  and  Dil.vtor  foe  Pelvic  Abscess. 
The  trocar  and  cannula  run  in  a  groove  between  the  blades  of  the  sharp- 
pointed  dilator.  Having,  with  the  trocar,  determined  the  presence  of  pus, 
the  closed  blades  of  tlie  dilator  are  pushed  on  into  the  cavity,  and  these 
are  then  separated  so  as  to  permit  of  the  enlargement  of  the  opening  and 
the  iuU  flow  of  fluid. 

find  the  most  distinct  sense  of  fluctuation,  and  the  trocar  is  guided 
to  this  spot  by  the  middle  and  index  fingers  of  the  left  hand.  The 
bulging  portion  is  now  pierced  with  the  trocar,  which  is  then  with- 
drawn, and  the  fluid  is  permitted  to  flow  ofi"  by  the  cannula  and 
tube.  There  should  be  no  meddHng  after  the  withrawal  of  the  fluid. 
Sterilized  iodoform  gauze  is  used  for  tamponing  the  vagina.  The 
greatest  care  is  necessary  for  several  days.  The  patient  is  kept  on 
her  back  and  the  pulse  and  temperature  are  watched.  The  bladder 
must  be  regularly  relieved  by  the  catheter,  and  it  is  well  to  keep  the 
bowel  quiet  for  a  few  days. 

If  it  be  decided  to  remove  any  clots,  either  from  the  quantity 
of  these  in  the  tumour  or  the  symptoms  of  septicaemia  being  immi- 
nent, we  must  determine  our  site  of  puncture  according  to  the 
character  of  the  swelling  and  the  situation  of  its  most  prominent 
surface.     The  posterior  cul-de-sac  of  the  vagina  will  be  found  the 


150  DISEASES   OF   WOMEN. 


most  suitable  and  convenient  place  to  explore.  An  aspirator  or  Lan- 
dau's instrument  should  first  be  used.  If  we  be  deceived  in  the  sense 
of  fluctuation,  and  find  either  a  smaller  quantity  of  fluid  than  we 
anticipated,  or  only  softened  clots — or  that  no  fluid  comes  with  the 
aspirator — the  question  immediately  arises,  should  we  not  lay  open 
the  mass  and  remove  the  clots?  The  decision  must  depend  on 
the  urgency  of  the  local  or  general  symptoms — pelvic  distress  in 
the  bladder  and  rectum  on  the  one  hand,  symptoms  of  septicsemia 
on  the  other.  It  is  impossible  to  lay  down  dogmatic  rules  for 
guidance  in  such  cases.  Each  individual  case  has  its  special 
peculiarities  and  bearings.* 

The  frequency  with  which  tubal  pregnancy  is  the  cause  of  the  effusion  has 
to  be  always  remembered.  Abdominal  section  is  here  the  clear  indication. 
Having  evacuated  the  contents  of  the  tumour,  1  in  1000  of  formalin  is  used 
to  wash  out  the  cavity  through  a  piece  of  tubing  attached  to  the  nozzle  of  an 
ordinarj'  syringe  or  the  cannula  of  the  aspirator.  Drainage  is  maintained  if 
necessary  by  sterilized  iodoform  gauze,  and  the  same  is  used  as  a  loose 
tampon  in  the  vagina. 

Intra-uterine  Medication. — In  gynaecological  practice  the  treat- 
ment of  uterine  dischai^ges  by  the  topical  application  of  agents  to 
the  uterine  canal,  both  of  cervix  and  body,  is  not  so  often  practised 
as  it  used  to  be,  since  the  operation  of  curettage  has  become  so 
frequent.  In  the  commonly  occurring  troubles — endometritis  (cer- 
vical and  corporeal),  granular  and  follicular  conditions  of  the  cervical 
canal,  discharges  consequent  upon  gonorrhoea — we  may  have  to 
make  applications  to  the  interior  of  the  uterus.  The  following  are 
some  of  the  more  important  therapeutic  agents  employed  : — 


Nitric  acid. 

Carbolic  acid. 

Chromic  acid. 

Iodoform  and  iodol. 

Iodine  (as  tincture  or  liniment). 

Ichthyol,    10    to    20    per   cent. 


Nitrate   of  silver   (solid  and    in 

solution). 
(Sulphate  of    zinc  (solid    and   in 
"     solution). 

Perchloride  of  iron  (in  solution). 
Trichloro-acetic  acid  (in  solution). 


solution,   used    alone   or  with  i       To    be    used    with   the   same 


glycerine. 
Iodine  and  carbolic  acid 


caution  as  nitric  acid,  and  the 

application     restricted     to     a 

limited  surface. 
Chloride  of  zinc  (in  solution). 
Hydrastis      Canadensis     (liquid 

extract. 
See  chapter  on  Pelvic  Haemorrhage. 


SOME  MIXOR   GYNJECOLOGICAL    OPERATIOXS.  151 

Mercury,  cocaine,  belladonna,  and  morphia,  are  best  applied  in 
the  form  of  bougies. 

I  have  found  the  liquid  extract  of  hydrastis  combined  with 
glycerine,  carbolic  acid,  or  liniment  of  iodine,  an  admirable  applica- 
tion in  cases  of  cervicitis  and  erosion  of  the  cervix,  I  can  say  the 
same  of  ichthyol. 

Intra-uterine  medication  is  practised  either  through  the  medium  of 
solid  substances,  the  introduction  of  ointments,  or  the  application 
and  injection  of  liquids.  These  are  applied  to  the  cervix  alone,  or 
to  the  cavity  of  the  body  of  the  uterus  above  the  cervix. 

While  many  women  are  insusceptible  to  the  effects  of  intra- 
uterine applications,  others,  on  the  contrary,  are  very  easily  affected 
by  such,  and  are  peculiarly  prone  to  suffer  from  uterine  colic, 
symptoms  of  collapse,  metritis,  or  peritonitis,  after  their  use.  Intra- 
uterine medication,  then,  is  always  to  be  undertaken  cautiously. 
Before  resorting  to  it,  the  woman  must  be  placed  in  the  best  possible 
position  to  undergo  this  form  of  treatment.  This  caution  is  all  the 
more  necessary  in  the  instance  of  those  applications  which  are  made 
above  the  os  internum.  Certain  general  precautions  are  applicable 
in  such  cases.     I  state  these  categorically. 


General  Precautions. 

Let  the  vagina  be  thoroughly  cleansed.  Have  the  patient's 
bowels  attended  to  by  the  administration  of  a  saline  purgative  ; 
rest  in  bed  is  essential  where  a  powerful  agent  is  carried  beyond  the 
isthmus  uteri.  Sufficient  patency  of  the  uterine  canal  should  be 
secured  before  we  proceed  to  treatment.  When  any  caustic  or 
strong  astringent  has  been  used,  an  antiseptic  tampon  should  be 
placed  in  the  vagina.  This  is  the  more  requisite  if  the  step  be 
taken  in  the  practitioner's  house,  and  if  the  patient  has  to  drive  or 
walk  any  distance  subsequently.  No  application  should  be  made 
immediately  before  or  after  a  menstrual  period.  The  safest,  most 
convenient  and  effectual  method  of  applying  any  remedy  to  the 
canal  of  the  uterus  is  by  means  of  the  uterine  cotton-wool  holder. 
The  probe  can  be  curved  to  any  shape,  so  as  to  pass  readily  into  the 
uterus.  It  is  well  to  have  two  holders,  as  one  is  necessary  to  clean 
out  the  uterus.  This  is  readily  done  by  rolling  a  layer  of  cotton- 
wool tightly  round  the  end  of  the  probe,  and  wiping  out  the  uterus 


152  DISEASES   OF   WOMEN. 

with  it.  At  times  a  difficulty  is  experienced  in  removing  the 
tenacious  plug  that  fills  the  cervix  in  some  cases  of  endome- 
tritis. By  placing  a  little  more  wool  on  the  probe,  and  rotating, 
we  may  detach  it ;  but  a  small  conical  sponge,  held  in  a  minia- 
ture sponge-holder,  will  answer  the  purpose  best. 

When  about  to  dress  the  uterus  in  the  manner  spoken  of,  it  is 
well  to  have  the  patient  on  a  couch  in  front  of  a  good  light.  The 
dorsal  decubitus  is  the  most  convenient.  [I  have  already  alluded  to 
the  mode  of  applying  nitric  acid  to  the  fundus  uteri.]  One  tampon 
of  wool  is  ready  to  hand,  and  some  half-dozen  small  pieces  are 
prepared  to  wipe  the  vaginal  roof  and  surface  of  the  uterus.  The 
cervical  canal  is  cleaned  out  and  dried,  and  the  uterine  probe, 
armed  with  the  cotton-wool  saturated  with  the  solution,  is  carried 
the  desired  length  into  the  uterus.  When  the  probe  is  withdrawn, 
the  vaginal  tampon  is  introduced. 

Of  the  substances  named,  the  strength  of  any  solution  selected  must  depend 
on  the  chai'acter  of  the  case  and  the  effect  we  desire  to  produce.  The  safest 
rule  for  a  surgeon  to  follow  is  to  select  a  medium  strength  of  any  medicament, 
and  never  to  begin  with  the  maximum  of  that  recommended.  On  the  whole, 
it  is  better  to  be  below  than  above  even  the  medium  strength  of  some  solu- 
tions. The  subjoined  are  those  that,  as  a  rule,  will  be  found  safe  and  service- 
able : — 

1.  Nitric  acid  (applied  as  directed,  p.  142),  pm-e. 

2.  Carbolic  acid  and  glycerine  two  parts  to  one,  and  equal  parts.    (Extract 

of  hydrastis,  one  part,  may  be  added.) 
.3.  Carbolic  acid,  glycerine,  and  tincture  of  iodine  :  equal  parts,  or  com- 
bined with  extract  of  hydrastis. 

4.  CarboHc  acid  and  ext.  hamamelis  (liq.) :  equal  parts. 

5.  Chromic  acid :  gr.  xx.-xxx.  ad  .^i. ;  or  the  same  solution  with  equal 

parts  of  glycerine. 
(■).  Iodine  :  gr.  xxx. ;  spt.  rectif.,  ad  ^i. ;  or  tincture,  with  equal  parts  of 
glycerine ;  or  the  liniment  of  iodine — pure. 

7.  Nitrate  of  silver  :  gr.  xx.-xxx.  ad  51. 

8.  Perchloride  of  iron :  gr.  xx.-xxx.  ad  .^i.  (glycerine  or  water),  with  one 
part  of  No.  2  Solution. 

9.  Sulphate  of  zinc  :  gr.  xxx.  ad  ^i. ;  or  with  one  part  of  No.  2  Solution. 

10.  Chloride  of  zinc  :  gr.  xxx.  ad  ^i. ;  or  with  one  part  of  No.  2  Solution, 

11.  Ichthyol  solution  10  to  20  per  cent.,  or  with  Nos.  2  or  6. 

12.  Formic  aldehyde  ith  to  1  per  cent.  It  is  a  good  plan  in  periodical 
dressings  to  vary  the  nature  of  the  application.  A  desired  effect  will  often 
follow  this  change  in  topical  treatment. 

Intra-uterine  Injection, — I  never  resort  to  intra-uterine  medicated  injec- 
tions into  the  cavity  of  the  uterus.  I  do  not  care  to  run  the  unquestionable 
risks  attendant  upon  their  employment.     'The  less  fluid  we  leave  in  the 


SOML-  MLSOi:   arXJSCOLOGICAL    OPEIiATIOXS.  153 

uterine  cavity  after  any  topical  application,  the  bettei*.  This  applies  with 
double  force  to  the  undilated  organ  when  metritis,  peritonitis,  collapse, 
colic,  cellulitis,  and  perimetritis  are  more  likely  to  follow  the  injection  of 
fluids.  If  they  be  used,  it  should  be  with  such  an  instrument  as  the  urethral 
injector  of  Sir  Henry  Thompson.  Such  an  intra-uterine  medicator  I  had 
made  for  me.  It  has  a  uterine  curve,  and  answered  well  for  introducing 
fluids.  It  contains  a  sponge,  moistened  with  the  solution,  whicli  is  carried 
down  to  the  apertures  in  the  curve  of  the  instrument,  and  thus  a  small 
([uautity  can  be  squeezed  througli  these  into  the  urethral  or  uterine  canal. 
Withdrawing  the  sponge  lightly,  we  can  permit  the  reflux  of  any  fluid  that 
may  remain,  before  removing  the  iustinimeut.  I,  however,  see  no  advantage 
to  be  gained  over  the  application  with  the  uterine  probe  and  saturated  wool. 
If  intra-uterine  injections  be  used,  we  must  be  careful  to — 

(1)  exclude  the  possibility  of  any  flexion  of  the  canal ; 

(2)  secure  free  exit  for  any  fluid  by  previous  dilatation  of  the  canal ; 

(3)  inject  (the  patient  being  in  bed)   within  a  week  after  the  menstrual 

period,  and  take  everj''  possible  precaution  to  anticipate  and  prevent 
subsequent  inflammation  ; 

(4)  avoid  the  admission  of  air  ; 

(5)  never  use  nitrate  of  silver  solution  by  injection  ; 

(0)  first  wash  out  the  uterus  with  a  little  warm  water,  to  ascertain  the 
uterine  sensitiveness. 

Tinctiu'e  of  iodine,  diluted  ;  carbolic  acid,  with  glycerine  and  water  ;  per- 
chloride  of  iron,  in  water  ;  chromic  acid,  in  solution  ;  sulphate  and  chloride 
of  zinc,  in  water — have  all  been  used.  The  strengths  should  be  weaker  than 
those  we  employ  of  the  same  agents  with  the  cotton  wool  and  probe. 

A  fairh^  safe  injector  to  use  is  a  small  glass  syi'inge  which  fits  accurately  to 
a  hollow  uterine  sound  with  fine  apertures  at  the  point.  Whatever  fluid  be 
employed,  at  the  most  only  five  to  ten  drops  should  be  injected  at  the  time. 
I  repeat  that  in  practice  I  believe  intra-uterine  injection  to  he  a  needlessly 
venturesome  plan  of  treating  unhealthy  endometric  conditions. 

I  never  now  use  any  ointment  in  intra-uterine  therapeutics. 

Intra-uterine  Crayons  and  Bougies. — Fused  sticks  are  sold  for 
the  purpose — as  those  of  Braxton  Hicks,  which  are  made  of  sulphate 
of  zinc.  I  have  altogether  abandoned  the  use  of  all  such  crayons 
and  bougies.  With  the  j^orte-caustique  bougies  of  iodol,  iodoform, 
cocaine,  belladonna,  iodide  of  mercury,  and  europhene  may  be 
introduced.  Nitrate  of  silver  is  used  in  combination  with  nitrate 
of  potash  made  into  small  moulds,  or  it  may  be  readily  fused 
in  a  little  platinum  crucible,  and  applied  on  the  point  of  a  uterine 
probe. 

Mauy  years  since,  Lombe  Atthill  advocated  intra-utei'ine  application  of  the 
solid  nitrate  of  silver  in  sub-involution  of  the  womb,  attended  by  severe 
menorrhagia,  regarding  it  as  '  both  simple  and  safe.'  These  substances  are 
applied  through  the  porte-caustique  (Fig.  122),  a  hollow  uterine  somid  open 


154 


DISEASES   OF   WOMEK. 


O 


at  the  end.     The  little  caustic  stick  is  inserted  into  this,  and  pushed  home 
into  the  uterus  by  the  stylet,  which  fits  the  tube  accurately.     But  we  must 

be  careful  to  withdraw  the  porte-caustique  a 
little  from  the  uterus  when  pushing  iu  the 
stick,  so  as  not  to  penetrate  the  uterine  wall. 

Intra  -  uterine  Suppositories.  —  Very 
small  suppositories  can  be  readily  had  ta 
order  from  any  good    chemist,  made  of 
cacao-butter    and    glycerine,    containing 
belladonna   (gr.  ii.  of  extract),  morphia 
(gr.   1 — ^),    carbolic   acid   (gr.  ii.),   iodo- 
form (gr.  iii.),  tannic  acid  (gr.  x.),  and 
alum  (gr.  x.)  ;  these  agents  may  be  used 
either   singly    or    in    combination.       To 
these  we  may  add  cocaine  or  eucaine  (gr. 
ii.).     They  can  be  inserted  through  the 
porte  -  caustiqiie.      I    do   not    recommend 
unctuous    or   greasy    substances.     I   be- 
lieve the  safest,  the  most  generally  con- 
'-^      ^E        i         b     venient,  and  the  most  efficacious  means 
a      ^g        "■         c3     of   treating  abnormal  states  of    the  en- 
>2     dometrium,  short  of  curettage,  is  by  the 
-^     aid  of  the  uterine  cotton-wool  holder. 
K        Potassa  Fusa  and  Potassa  cum  Calce. 
^     — Both  these  caustics,  the  former  being 
[     the  more  deliquescent  and  powei'ful,  are 
22     by  some  surgeons  employed  in  malignant 
g     disease  of  the  uterus.     They  require  to  be 
"^      used   with    considerable    caution.     I    do 
not  myself  now  employ  either   of  these 
agents.  '    They    are   thus    applied :    The 
patient  is  placed  in  the  dorsal  position, 
with  the  legs  drawn  up  and  held  apart. 
A   large-sized    Fergusson's    speculum    is 
introduced,  and  the  cervix  brought  well 
within  the  tube.     Some  absorbent  cotton- 
wool, saturated  with  vinegar,   is  packed 
round  the  lower  part  of  the  cervix,  sepa- 
rating the  rim  of  the  speculum  from  the 
part    to    which   the    caustic    has    to    be 
applied.     The  pencil  of  caustic  is  now  taken  in  the  holder,  and  used 


d 


SOME   MIXOR    OYX^COLOafCAL    OPEJ;A770XS.  155 

lightly  or  otherwise,  according  to  the  desired  object.  The  more 
freely  it  is  rubbed  on,  the  greater  the  depth  of  tissue  destroyed, 
and  the  larger  the  slough.  A  stream  of  vinegar  and  water  is  then 
directed  on  the  part,  the  wool  having  been  removed,     A  pledget 


Fig.  124. — Sjiall  Platixum  CnuciBLi-;  fok  fusint,  Nituati-:  dv  Silvei;. 

of  cotton-wool,  soaked  in  equal  parts  of  vinegar,  glycerine,  and 
water,  is  now  pushed  up  against  the  cervix,  and  allowed  to  remain 
in  the  vagina.  Uterine  pain  is  relieved  by  a  subcutaneous  injection 
of  morphia,  and  a  belladonna  and  morphia  suppository  introduced 
into  the  vagina. 

[The  method  of  applying  chloride  of  zinc  in  solution  or  paste  is  described 
in  the  chapter  dealing  with  the  treatment  of  malignant  disease  of  the  uterus.] 


The  Operation  of  Curettage. 

The  Use  of  the  Uterine  Curette. — The  value  of  curettage  of  the 
uterus  as  a  therapeutical  step  in  diseased  conditions  of  the  endo- 
metrium cannot  be  too  strongly  insisted  on.  In  chronic  endometritis, 
in  the  case  of  fungosities  of  the  cavity  of  the  body,  in  gTanular 
endocervical  conditions,  in  htemorrhagic  endometritis,  in  the  instance 
of  small  mucous  polypi  attendant  upon  follicular  degeneration  of 
the  endometrium,  for  placental  polypi  and  the  granulations  which 
remain  after  adhesions  following  discharge  of  the  ovum,  in  the  case 
of  soft  growths  which  we  are  apprehensive  are  of  a  malignant  nature, 
the  use  of  the  curette  is  indicated.  Many  of  these  states  are 
attended  with  persistent  or  recurring  htemorrhage.  Properly 
conducted  curettage,  completed  by  the  application  of  chromic  acid 
to  the  uterine  cavity,  has  superseded,  in  my  practice,  all  that 
tedious  and  unsatisfactory  medication  of  unhealthy  states  of  the 
endometriimi  which  exhausts  the  patience  of  the  surgeon  and  the 
confidence  of  the  patient. 

In  the  majority  of  operations  of  curettage  if  is  not  necessary  to 
dilate  the  cervical  canal  beforehand,  as  it  is  already  either  sufficiently 
patent  to  admit  a  large-sized  curette,  or  it  can  be  made  so  at  the 
time  of  operation  by  the  use  of  dilators.  In  other  cases  in  which 
there  is  more  or  less  contracted  isthmus,  or  in  which  we  wish  to 
explore   the    uterus    di.gitally,    as   well    as   to  curette    it,   previous 


156 


DISEASES   OF   WOMEN. 


dilatation  with  laminaria  tents  is  the  plan  I  always  adopt.     I  then 
take  the  following  precautions  : — 

Previous  Use  of  Antiseptic  Tents. — Tents  of  different  sizes  are  kept 
in  a  saturated  solution  of  iodoform  in  ether  (p.  81).  They  are  taken 
direct  from  this  solution  for  use.  The  vagina  having  been  previously 
well  douched  with  a  lysoform  solution  and  tamponed,  the  patient 
is  placed  on  a  table  in  the  dorsal  position.  The  duck-bill  speculum 
is  used.  The  uterus  is  drawn  well  down  with  a  tenaculum.  The 
vagina  is  now  thoroughly  douched  out  with  an  antiseptic.  One  or 
two  tents  (they  should  be  from  four  to  five  inches  in  length)  are 
selected  and  given  the  necessary  curve.  The  uterus  is  steadied,  and 
the  tent  or  tents  are  pushed  home.     It  is,  as  a  rule,  preferable  to 


Landau's  curved  knife  is 
useful  for  final  cleaning  out 
of  the  uterine  cavity  when 
there  has  been  much  debris, 
also  for  the  removal  of 
granulations  of  the  cervix 
and  irregularities  around 
the  external  os  in  cases  of 
erosion. 


Fig.  125.    Fig.  126.      Fig.  127.    Fig.  128.-Curved  Blade  of 

Vaeious  Uterine  Curettes.  Landau's  Knife. 

Actual  sizes.  The  blade  is  \  inch  wide. 

introduce  only  a  single  tent  at  the  first  application.  The  vagina 
is  now  loosely  tamponed  with  iodoform  or  chinosol  gauze,  and  the 
patient  is  put  to  bed. 

Supposing  this  application  to  be  made  in  the  morning,  the 
dilatation  needful  for  ordinary  curettage  will  be  secured  by  midday, 
or,  if  at  night,  by  the  following  morning.  Should  further  dilatation 
be  required,  as  for  exploration,  the  patient  is  again  placed  on  the 
table,  and,  after  the  removal  of  the  tampon  and  tents,  the  vagina  is 
again  thoroughly  douched,  and  the  cavity  of  the  uterus  is  wiped 
o°t,  with  ^^  perchloride  solution.  The  longer  tent  or  tents  are 
then  introduced.     I  complete,  at  the  time  of  operation,  the  needed 

dilatation  with  my  larger-sized  metal  bougies  or  those  of  Leiter. 
With  such   precautions,  it  is  not,'  I  believe,  possible  that  any 


SOME   MIXOl!    GYNJECOLOOICAL    OPI-UATfONS. 


157 


septic  effects  can  follow  the  use  of  tents.  No  bad  consequence 
has  ever  attended  upon  any  operation  in  my  practice  from  this 
means  of  dilatation. 

Operation. — The  patient,  having  had  an  aperient  the  previous 
night,  and  an  enema  the  following  morning,  is  placed  on  the  table, 
under  an  antesthetic,  in  the  usual  dorsal  position.  The  large  duck- 
bill or  other  vaginal  retractor  is  used  to  expose  the  uterus,  which 
is  drawn  down  with  a  tenaculum.     If  a  tent  has  been  used,  this  is 


Fig.  129. — Light  Metal  Spoon  Cokktte. 

withdrawn.  The  vagina  is  now  thoroughly  sterilized  in  the  manner 
already  described.  A.  Martin's  curette  (Fig.  130)  is  then  taken 
and  introduced  as  far  as  the  fundus,  and  by  rotatory  movements 
the  curettage  of  the  cavity  of  the  uterus  is  effected.  This  is 
continued  as  far  as  the  cervix.     The  sharper  curette  (Fig.  125),  or 


Fig.  130. — A.  Maktin's  Cdeette. 

other,  as  is  deemed  necessary,  according  to  the  character  of  the  case 
and  the  size  of  the  particles  to  be  detached,  is  next  introduced,  and 
the  denuding  process  is  completed.  I  prefer,  when  we  have  reason  to 
suspect  products  of  conception,  to  use  the  large  spoon  curette  (Fig. 
127).     The  selection,  however,  will  greatly  depend  on  the  resistance 


Fig.  131. — Cuuette  Foeceps  of  Noble. 


of  the  tissues  on  the  spot  we  are  operating  upon.  With  a  fine  long 
pipette  the  uterine  cavity  is  washed  out  from  time  to  time,  and 
when  the  curettage  is  completed  it  is  mopped  out,  with  strips  of 
sterilized  gauze,  carried  well  in  on  slender  forceps,  as  shown  in  Figs. 
132,  133.     It  is  now  dried  out  with  iodoform  gauze,  and,  if  it  be 


158 


DISEASES   OF   WOMEN. 


indicated,  the  uterine  probe  with  cotton-wool  tightly  rolled  on  it 
is  dipped  in  chromic  acid  solution  (grs.  xxx. — 5  i.  to  the  ounce), 
and  is  carried  into  the  uterine  cavity,  and  the  application  of  the 
acid  is  made.  The  vagina  and  cervix  are  now  dried,  and  finally  a 
strip  of  sterilized  iodoform  gauze  is  carried  into  the  uterine  canal, 
and  the  vaginal  end  tied  with  silk,  which  is  distinguished  by  one  knot 


Fig.  132. — Slender  Olamp  Forceps  for  carrying  Gauze  into  the  Uterine 

Cavity. 

being  made.  A  larger  strip  of  moist  iodoform  gauze  is  tied  in  the 
middle.  Either  end  is  carried  up  at  each  side  of  the  vagina  so  as 
to  include  the  cervix  and  cover  it ;  this  piece  of  silk  thread  is  tied 
with  a  double  knot,  and  finally  some  sterilized  gauze  from  a^  roller 
is  carried  into  the  vagina,  care  being  taken  to  keep  the  strings 
securing  the  iodoform  free  from  and  outside  the  gauze.  These 
tampons  are  not  disturbed  for  forty-eight  hours.  It  is  well  to  give 
a  bromide  of  potassiu^m  mixture  at  intervals  for  the  first  twenty-four 
hours,  and  to  place  a  trional  suppository  in  the  rectum  the  night  of 


Fig.  133. Slender  Intee-Uterine   Forceps   for  wiping   out   the   Uterine 

Cavity  with  Gauze  or  Cotton  Wool;   h,  end  of  same  when  covered 
WITH  Cotton  Wool. 

TLis  latter  is  firmly  secured  by  enclosing  a  portion  of  the  wool  between  the 
blades,  and  then  wrapping  it  round. 

the  operation.  It  is  my  practice,  after  forty-eight  hours,  to  tampon 
the  vao-ina  loosely  for  the  first  week  with  moistened  chinosol  or 
sterilized  iodoform  gauze.  After  this  it  is  well  to  use  a  daily 
antiseptic  douche  for  another  week.  • 


SOME  MINOR   GYNAECOLOGICAL    OPERATIONS. 


159 


It  is  now  clearly  established  that  tlie  endometrium,  after  an 
aseptic  curettage,  is  reproduced  in  its  entirety  within  a  period  of 
from  eight  to  ten  weeks.  The  contrast  between  the  normal  appear- 
ance of  the  mucosa  after  the  curette,  and  after  the  employment 
of  caustics,  is  marked.  In  the  latter  case,  there  is  an  atrophic 
condition,  with  absence  of  the  glands  and  excess  of  the  connective 
tissue. 


c— . 


i.-. 


c  — 


Fig.  134. — Vertical  Section  of  the  Utekus  Three  Months  after 
Curettage.     (Baldy.) 

a,  epithelium ;  b,  uew-formed  glands  ;  c,  connective  tissue ;  d,  muscular  tissue ; 

vv,  blood-vessels. 

Dangers  of  Dilatation  and  Curettage. — The  point  must  be  empha- 
sized that  curettage,  especially  in  chronic  cases  of  uterine  aflfection, 
is  not  without  its  risks.  This  remark  applies  particularly  to  the 
operation  when  it  is  carried  out  with  the  aid  of  dilatation  in  women 
in  whom  there  may  be  reason  to  suspect  past  trouble  of  the  adnexa. 
Dormant  states  of  the  ovary  and  tube  may  be  roused  into  acute 
disturbance,  and  suppurative  mischief  in  the  adnexa  may  be  started. 
This  may  occur  even  though  every  conceivable  care  and  precaution 
has  been  taken  in  carrying  out  the  operation. 

Case  of  Pelvic  Abscess  following  Curettage. — A  lady,  aged  forty-two,  bad 
previously  bad  the  uterus  dilated  and  explored.  I  again  dilated  tbe  uterus, 
and  tbe  unbealtby  portion  was  curetted.  Carbolic  acid  was  applied  to  tbe 
cavity.  Sbe  bad  bad  most  profuse  baemorrbage  for  some  months  from  a 
large  subinvoluted  uterus.  There  was  some  attendant  endometritis.  On 
the  third  day  sbe  bad  a  severe  attack  of  uterine  colic.  This  was  followed  by 
a  long  and  anxious  time,  during  wliicb  an  abscess  formed  in  tbe  left  broad 
ligament,  which  was  opened  from  the  abdomen  and  drained.     Tbe  patient 


160  DISEASES   OF   WOMEN. 

finally  made  an  excellent  recovery,  and  from  the  date  of  the  operation  to 
the  present  time  there  has  been  no  bleeding.  This  is  the  only  instance  in 
which  any  complication  has  followed  the  operation  in  my  hands. 

Christopher  Martin,  in  a  paper  entitled  '  When  and  how  to 
curette  the  Uterus,'  confirms  the  caution  I  have  given  in  the  text 
with  regard  to  salpingitis,  and  also  curettage  for  bleeding  myoma. 

'  I  have  seen,'  he  says,  refemng  to  curettage  when  there  is  old  or  recent 
septic  or  gonorrhoea!  inflammation  of  the  adnexa,  '  a  slumbering  salpingitis 
converted  into  a  virulent  and  fatal  pyo-salpinx  by  such  a  proceeding.'  Again,, 
his  criticism  on  temporizing  with  offensive  discharges  or  hsemorrhage,  due  to 
the  retention  of  the  products  of  conception,  cannot  be  too  strongly  empha- 
sized, though  in  these  cases  special  care  has  to  be  taken  with  regard  to 
dilatation  and  antisepsis. 

I  cannot  but  agi'ee  with  his  comments  on  curettage  as  a  palliative  for 
haemorrhage  consequent  upon  simple  myoma.  I  am  convinced  that  '  useless 
scraping '  of  the  endometrium,  as  is  sometimes  done  in  these  cases,  is  attended 
with  risks  of  sepsis,  and  is  of  no  permanent  benefit.  In  cases  where  it  may 
be  thought  necessary,  oophorectomy  is  a  far  preferable  procedure.  As  to 
cancer,  he  makes  the  practical  comment  that,  '  at  best,  the  respite  is  short, 
and  in  many  cases  when  the  disease  again  manifests  itself  it  advances  with 
fearful  rapidity.  When  the  growth  is  strictly  limited  to  the  cervix  or  the 
endometrium,  we  should  offer  the  patient  the  more  certain  hope  of  cure 
afforded  by  vaginal  exth-pation  of  the  uterus.  If  the  disease  be  too  far 
advanced  for  this  operation,  the  less  we  interfere  with  it  the  better.' 

On  the  other  hand,  it  is  only  right  to  say  that  I  have  had  some 
excellent  results  in  cases  of  myoma  in  temporarily  arresting  haemor- 
rhage, where  the  patient  would  submit  to  no  operation  other  than 
curettage,  and  in  which  the  use  of  the  curette  was  followed  by  an 
application  of  chromic  acid. 

Orlofi"  also  advocates  the  operation  in  such  cases,  as  allowing 
time  for  recuperation  in  small  fibroids  which  do  not  cause  pain, 
and  in  those  instances  where  the  menopause  is  approaching. 

In  two  important  communications  made  to  the  Obstetric  and  Gynaeco- 
logical Society  of  Paris,  June,  1895,  by  Bonnet  and  Fournel,  and  quoted  by 
Edge  in  the  British  Oynaxological  Journal,  February,  1895,  p.  384,  the 
relative  indications  and  contra-indications,  advantages  and  disadvantages, 
and  the  dangers  of  dilatation  of  the  uterus  and  drainage,  are  clearly  set  out. 

The  conclusions  of  Fournel  show  a  very  strong  bias  against  dilatation 
in  peri-uterine  lesions.  He  argues  that  the  normal  uterus,  if  tamponed, 
gives  forth  a  discharge  ;  that  dilatation  cannot  possibly  touch  many  of 
the  diseased  states  of  the  adnexa ;  he  disagrees  with  Doleris  as  regards 
the  success  and  efficiency  of  the  treatment.  While  allowing  for  its  indi- 
cation  in  non-suppurative   conditions  suitable  for  expectant  treatment,  he 


SOMK   ML\01!    <IY.\\W:0L0(11CAL    OPEJIATIOSS.  IGl 


condemns  it  in  suppurating  lesions,  and  emphasizes  the  caution  that  dilatation 
causes  indirect  mischief  to  the  general  healtli  as  well  as  to  the  pelvic  organs. 
He  asserts  tliat  the  fatal  results  of  such  radical  operations  as  oophorectomy 
and  hysterectomy  have  their  mortality  increased  hy  ])revious  dilatation. 
Bonnet,  on  the  other  hand,  agrees  with  Walton,  Poullet,  Doleris,  Labadie- 
Lagi-ave,  and  others,  on  the  efficacy  of  dilatation,  curettage  and  drainage  in 
salpingitis,  and  in  alVections  of  the  adnexa  complicating  displacements  of  the 
uterus.  He  says :  '  I  have  never  seen  a  fatal  result,  nor  any  aggravations 
of  the  lesions  of  tlie  appendages,  when  the  treatment  has  been  carried  out 
properly  and  gradually.'  In  recent  cases  of  cellulitis,  and  in  cystic  con- 
ditions of  tiie  endometrium,  he  advocates  dilatation. 

The  trutli  I'egnrding  dilatation  and  curettage  may  be  placed  as 
midway  between  the  views  of  its  advocates  and  opponents.  In 
such  capable  hands  as  those  of  Olshausen,  death  has  followed  from 
dilatation  ;  and  that,  even  with  the  greatest  care  and  complete 
antiseptic  precautions,  alarming  symptoms  may  arise  consequent 
upon  its  employment,  has  been  proved  to  myself.  This  I  have  shown 
in  a  case  in  which  pelvic  abscess  followed.  True,  I  have  never  had 
in  my  own  practice  a  fatal  issue,  and,  with  the  exception  quoted, 
never  any  unpleasant  consequence ;  but  I  have  thus  emphasized  the 
unfavourable  possibilities  of  the  procedure,  in  order  to  draw  attention 
to  the  unavoidable  risks  that  are  occasionally  associated  with  it, 
especially  if  it  be  carried  out  without  stringent  aseptic  precautions. 
This  risk  may  be  largely  increased  should  it  be  performed  in 
ignorance  oi  the  fact  that  there  is  an  ectopic  gestation  present. 


CHAPTER   VI. 

SOME    REMARKS    ON    SUTURES  AND    LIGATURES. 

Catgut  Suture. — For  most  gynfecological  operations  I  use  catgut  for 
all  buried  sutures,  and  celloidinzwirn  for  the  skin.  There  is  a 
divergence  of  opinion  amongst  operators  as  to  the  superiority  of 
silk  or  catgut.  Equally  eminent  and  distinguished  surgeons  use 
both  materials  in  their  technique.  In  suturing  the  intestine,  the 
stomach,  or  the  omentum,  silk  is  preferable,  but  for  all  other 
purposes  in  gynaecology  I  prefer  cumol  gut,  chromocized  cumol  gut, 
or  that  prepared  by  Martin's  method,  as  has  been  already  described. 
The  latter  ties  easily  and  rapidly,  does  not  slip,  nor  cause  stitch 
abscesses,  and  resists  absorption  for  a  sufficient  length  of  time  to 
prevent  any  fear  of  haemorrhage. 


Fig.  135. — Czerny's    Fig.  136. — Lembekt's    Fig.  137. — Gussek- 
SuTUEE.  Suture.  baur's  Suture. 

Of  kangaroo  tendon,  introduced  by  Marci  of  Boston,  I  have  no 
personal  experience.  It  is  stronger  and  more  slowly  absorbed  than 
catgut.  Bronze  aluminium  wire  as  used  by  Bumm  also  makes  an 
admirable  skin  suture,  while  silver  wire  is  to  be  preferred  as  a  buried 
suture  in  hernia,  and  for  deep  lacerations  of  the  cervix,  as  well  as 
in  the  closure  of  some  fistulse.  Silkworm  gut  is  preferred  by  some 
operators  as  a  buried  suture,  and  also  for  the  skin.  Horsehair  is 
not  used  much  now.  For  plastic  operations,  celloidinzwirn,  silk, 
and  silver  wire  are  the  best  materials. 

With  regard  to  special  sutures,  a  brief  reference  to  the  most  important 
employed  by  the  gynsecologist  must  be  useful  to  the  surgeon.    The  subjoined 


SOME   It  EM  AUKS   OX  SUTURES  AND    LIGATURES. 


163 


figures  and  those  which  follow  them  are  taken  from  the  valuable  work  of 
Pozzi.* 

Figs.  135-137  represent  the  three  well-known  methods  of  Czern)',  Lem- 
bert,  and  Gussenbaur  of  suturing  the  intestine. 


The  Suture  'a  Points  S^pares.' 
The  principle  of  this  form  of  suture  is  to  secure  complete  coaptation  of  the 


sides  of  the  wound  by  passing  three 
threads  at  ditferent  distances  from  its 
margin,  from  one  side  to  the  other  of 
it.  The  first  of  these,  the  farthest 
from  the  edge,  is  passed  deeply  and 
completely  beneath  the  exposed  sur- 
face, and  is  brought  out  at  a  con-e- 
sponding  point  on  the  other  side.  The 
second  is  not  carried  altogether  under- 
neath, but  appears  crossing  a  portion 
of  the  wound ;  while  the  third,  or 
most  superficial,  simplj-  binds  together  its  divided  margins 
sutures  (those  first  passed)  are  tied  last. 


cb 


Fig.  138. — Positiox  of  the  Three 
Threads  ix  the  Suture  '  a  Points 
Sepakes.' 


The  deepest 


Simple  Continuous  Suture. 

This  is  made  by  securing  one  end  of  the  gut  or  silk  with  three  knots  at  an 
angle  of  the  woimd.    This  terminal  point  of  the  gut  or  silk  is  held  in  a  forceps 


Fig.  139.— Simple  Continuous  Sutube 
coMiiENXED.  Forceps  holding  the 
detached  stitch  at  the  angle  of  the 
wound. 


Fig.  1-10. — Continuous  Suture 

NEARLY    finished. 


'  Traite'  de  Gynsecologie.' 


16t 


DISEASES   OF   WOMEN. 


by  an  assistant ;  the  gut  is  now  carried  in  continuous  loops  at  a  distance  of 
two  millimetres  from  the  margin  of  the  wound  until  it  arrives  at  its  other 
end,  being  drawn  fairly  tight.  A  little  care  is  required  that  the  consecutive 
stitches  are  adjusted  with  equal  tightness. 


Suture  a  Etages. 

When  tlie  simple  continuous  suture  is  obviously  insufficient  from  the  size 
or  depth  of  the  wound  to  close  it,  this  variation  is  suggested.  When  it  has 
reached  the  widest  portion  of  the  wound,  the 
thread  is  carried,  not  through  the  margin,  but  at 
some  distance  througli  the  deeper  tissues  in  the 
same  continuous  fashion,  thus  diminishing  its 
width  for  the  extent  desired  by  the  operator. 
The  needle  is  then  again  carried  through  the 
supei-ficial  stinictures,  the  wound  l^eing  iinally 
closed  by  a  further  continuation  of  the  original 
suture.  In  some  instances  it  may  be  necessary 
to  insert  two  or  three  of  these  superimposed 
threads  in  the  centre  of  the  wound,  in  order  to 
sufficiently  contract  the  deeper  tissues.  Care 
must  be  taken  not  to  draw  the  sutures  too  tightly, 
and  thus  to  approximate  too  closely  the  separate 
stitches. 

In  passing  the  sutures,  should  the  thread  be 
either  cut  or  broken,  another  is  inserted  at  the 
same  level,  knotted,  and  the  stitches  are  con- 
tinued. Where  the  tension  is  great,  the  insertion 
of  a  few  separate  superficial  stitches  of  silver  wire 
or  catgut  is  useful. 
The  ftxiill  Suture. — Pozzi  prefers  small  rolls  of  iodoform  gauze  as  quills  in 


Fig.  m. — 'SuTCBE  a 
Etages.'  Three  over- 
lying sutures  in  the  mid- 
dle of  the  wound. 


Fig.  142. — Surgeon's        Figs.  143,  144. — Oedixaby  Loop-knot  fob 
KxoT.  Pedicle.     (Dorax.) 

Fig.  14.3,  Passing  of  loop  before  withdraw- 
ing needle :  Fig.  144,  Crossing  of  threads. 

the  use  of  the  quill  suture,  and  in  certain  cases  he  uses  long  and  deep  sutures, 
wliich  are  retained  by  rolls  of  iodoform  gauze  folded  over  the  abdominal  wall. 


.^OMK   nK^tARI<S   ON  SUTi'IlES  AM>    IJilATlUKS. 


IGo 


For  ligatures,  whether  in  tying  en  masse  or  separately,  catgnt  is  tho 
preferable  material  for  intra-pcritoneal  purposes.  And  for  such,  it  has  in  tin' 
liaiuls  of  the  majority  of  surgeons,  almost  entirely  superseded  silk. 


Fig.  14.5. — BAXTocK'.-i 
Knot. 


Fig.  146.  —  Tait's 
'  Staffordshirk  ' 
Knot. 


Fig.  147. — Chain  Liga- 
ture ox  Pkdicle, 
Theeads       crossed. 

(DORAX.) 


Fig.  148. — Chaix  Ligature 

BEING        applied       OX       A 

Membraxous  Pedicle. 


Figs.  149  axd  150  show  the  Method  of 
making  Consecutive  Loops  op  the 
Chain  Ligature. 


Fig.  151. — Loops  of  Chaix 
Ligatures. 

a,  a,  a  mark  the  points  where 
these  are  cut  for  knotting. 


Fig.  152.— Showing  the  Threads  crossed, 
kxotted,    axd    ready    for    tightex- 

IXG. 


Fig.  142  represents  the  surgeon's  knot  made  ;  Fig.  143,  the  method  ot 
tying  the  pedicle  by  piercing  it  -nith  a  double  thread,  which  is  then  cut,  and 


166  DISEASES   OF   WOMEN. 

both  ends  knotted,  as  shown  in  Fig.  144 ;  or  the  thread  is  passed  through 
the  loop,  as  is  done  by  Ban  took  (Fig.  145)  ;  or  the  '  Staffordshire  knot '  (Fig. 
146)  of  Lawson  Tait  is  adopted.  In  this  latter  the  pedicle  is  transfixed  with 
a  blunt-pointed  or  aneurism  needle  armed  with  a  double  thread.  The  needle 
is  not  withdrawn.  Through  the  loop  thus  formed  are  brought  the  ends  of  a 
ligature  carried  loosely  round  the  pedicle.  The  needle  is  now  withdrawn,  by 
which  means  the  ends  of  the  pedicle  ligature  are  brought  back  through  the 
pedicle  and  lie  above  their  own  loop.  One  of  these  ends  is  passed  under  the 
loop,  and  both  are  tied  firmly.  They  are  again  carried  round  the  pedicle, 
and  once  more  firmly  tied. 

Chain  Ligature. — This  form  of  ligature  is  useful  in  flattened  pedicles,  and 
in  tying  membranous  adhesions.  Figs.  145-152  show  sufficiently  the  method 
of  tying  these. 

Mattress  Suture. 

Another  admirable  form  of  buried  suture  is  the  mattress  suture. 
It  is  made  with  silver  wire.  Its  typical  use  is  in  closing  the  mus- 
cular tissues  and  fascia  in  the  operation  for  hernia.  Two  needles 
are  threaded  with  the  wire.  One  is  darned  once  through  the  tissues 
at  one  side  of  the  wound,  and  is  then  brought  out  and  passed 
through  the  structures  at  the  opposite  side ;  the  other  needle  is 
passed  in  a  similar  manner,  and  a  loop  is  thus  left  at  either  side. 
Similar  loops  to  the  number  required  are  then  passed.  The  free 
ends  of  the  wire  are  next  pulled  together,  twisted,  and  cut  off  close. 

The  following:  case  well  illustrates  the  advantage  of  this  suture  : — 


Large  Hernia  following  on  Repeated  Coeliotomy  Operations.* 

This  was  the  largest  post-operative  hernia  I  have  ever  seen.  The  draw- 
ing (taken  from  a  photograph)  gives  only  a  partial  idea  of  its  extent. 
When  I  saw  the  patient  the  bowel  was  down  in  a  large  sac  which  protruded 
over  the  pubes,  Avhere  there  was  a  more  defined  pouch,  covered  only  by  the 
integument  (Fig.  153).  A  large  space  of  several  inches  separated  the  recti 
muscles  and  fascia.  The  bowel  appeared  to  be  adherent  in  parts  to  the 
parietal  covering.  She  was  subject  to.  recurrent  attacks  of  severe  pain,  and 
had  to  be  confined  to  bed  for  several  weeks  before  operation.  This  was  due 
to  attacks  of  subacute  peritonitis.  The  old  cicatrix  extended  from  a  short 
distance  below  the  umbilicus  to  about  two  inches  above  the  pubes.  Coeliotomy 
had  been  twice  performed.  I  did  not  learn  until  the  day  of  the  operation 
that  the  abdominal  wound  had  been  closed  after  the  last  operation  without 
sutures,  the  parts  having  been  brought  together  by  adhesive  plaster.  The 
steps  of  the  operation  may  be  understood  by  the  accompanying  diagram 
(Fig.  154).  Having  carefully  incised  the  skin  (c  c)  in  the  middle  line  over 
the   cicatrix   by   a   cautious   dissection  vertical   to   the   bowel,   which   was 

*  Lancet,  October  18,  1901. 


w 

^Br 

^^m- 

^^^R- 

^'          flA ' 

M|P> 

^^"'^ 

^fc^"'"'^6*f.SEV«^BijL_ 

Fig.  153. — Post-operath^e,  Abdominal  Hernia.*    (From  Photograph.) 
Before  operation. 

5kn        ,.-SKin 


1     1 

^ 

'     1 

1     ' 
1     1 

1     ' 

__ 

■ "(     r 

1            \ 

1 

^K 


^    %^- '^' 


Fig.  154. — Method  of  closing  the  Abdominal  AVound. 

*  The  drawing  does  not  sufficiently  represent  the  large  protrusion  of  the 
bowel  that  was  present. 


168 


DISEASES   OF   WOMEN. 


immediately  subjacent  to  it  and  adherent,  it  was  reflected  back  to  the 
extent  of  three  inches  at  either  side  (c').  Some  dense  fascia  (b)  was  exposed 
which  was  continuous  with  tlie  peritoneum  and  the  fascia  of  the  rectixs  (a  a). 
This  fascia  also  was  raised  and  reflected  back,  the  dissection  including  a 
portion  of  the  rectus  sheaths  (a  a).  All  bleeding  points  from  adhesions  of 
the  bowel  were  secured.  The  whole  omentum  and  bowel  were  then  covered 
with  a  sterilized  napkin  wrung  out  of  warm  formalin  solution.  Mattress 
sutures  were  then  carried  from  side  to  side  in  the  following  manner.  Two 
straight  ovariotomy  needles,  each  threaded  with  fairly  strong  silver  wire, 
were  passed  parallel  from  the  outer  border  of  the  rectus  including  the 
fascia,  across,  and  passing  under  the  dissected  fascia  were  brought  out  at 
corresponding  points  on  the  opposite  side.     Six  of  these  sutures  were  carried 


Fig.  155. — After  Operatiox.    (From  Photograph.) 

alternately  in  the  manner  shown  in  the  xlrawing,  and  a  single  strong  wire 
was  passed  at  the  upper  and  lower  angles  of  the  wound.  The  central  ones 
were  separated,  and  the  napkin  was  caught  in  the  centre  and  readily  with- 
drawn between  the  sutures.  These  were  then  tightened,  and  the  ends,, 
twisted  and  cut  close,  were  buried  in  the  rectus  muscle  at  either  side.  This 
brought  a  line  of  rectal  fascia  into  apposition  with  the  muscle  and  the 
underlying  peritoneum,  leaving  a  raised  flap  of  fascia  which  projected  at 
either  side  for  the  entire  length  of  the  incision.  This  was  pared  and  made 
to  overlap,  and  then  closed  with  silkworm-gut  sutures,  which  were  cut  short. 
The  skin  margins  were  then  united.  There  has  been  no  trouble  whatever 
since  the  operation.  She  continues  perfectly  well,  and  has  had  no  trouble 
up  to  the  present  time.* 

*  In  another  case,  there  had  been   a   large  congenital  inguinal  hernia  the 


SOMA-   /.'/.-.)/.  17.' A'.>    OX  Srn'L'LS  AX/>   LIOATUnES. 


169 


Bumm  (Halle)  lays  special  stress  in  these  cases  of  large  hernia  on  securing 
free  mobility  of  the  fascial  margins  by  complete  separation  of  the  rectus 
sheath  from  the  muscle,  and  division  of  the  outer  margin  of  the  latter  so  as 
to  relieve  the  tension  in  bringing  the  fascial  edges  together.  Also,  he 
emphasizes  the  importance  of  flejion  of  the  fritnJc  vhile  suturinr/.  He 
employs  bronze  aluminium  wire  for  the  skin,  thus  avoiding  any  interference 
of  the  wound  for  three  weeks. 


Zweifel  Suture. 

A  very  admii-able  and  readily  made  suture  is  that  used  by  Zweifel,  and 
known  as  the  Zweifel  suture.  It  is  made  with  two  needles,  one  handled 
and  curved,  the  other  short  and  blunt  Avith  one  end  split  to  hold  the  suture 
(Fig.  LoO).     There  are  two  principal  forms  of  suture.     One,  a  simple  con- 


Fro.   156. — ZWKIFEL   XeEDLEs. 


tinuous  suture,  is  made  as  follows  :  The  silk  or  gut  having  been  fixed  in  the 
straight  blunt  needle,  and  the  curved  one  threaded  from  its  concave  side,  the 
end  of  the  silk  with  the  handle  of  the  needle  is  secured  by  the  hand. 

The   concave   needle  is  caiTied  through  the  two  layers   of  peritoneum 
(Xos.  1  and  2),  and  the  straight  short  needle  in  the  left  hand  on  the  other 


side  is  passed  through  the  loop  that  is  formed  (No.  2).  The  needle  is  thei/ 
withdrawn  while  the  threads  are  pulled  on  equally  (No.  .3).  In  this  way  the 
two  surfaces  of  the  peritoneum  are  joined,  and  so  proceeding  up  the  wound 
a  lateral  continuous  suture  is  rapidly  made  (Nos.  4  and  5).  In  the  second 
kind  of  suture,  the  first  three  steps  are  the  same  as  in  that  just  described, 
but  after  the  curved  needle  has  been  brought  back,  and  before  it  pierces  the 
tissue  again,  the  short  needle  is  carried  under  the  thread  at  that  side,  and 
brought  to  the  other  side  (Nos.  7,  8,  9),  and  again  the  steps  are  the  same  as- 
in  the  first  instance.     The  method  is  continued,  gi^^ing  a  series  of  locked 

abdominal  wall  had  given  for  over  seven  inches  a1x)ve  the  external  ring  (some 
years  have  elapsed  since  I  operated),  burying  the  silver  mattress  sutures,  and  the 
patient  is  perfectly  well. 


170 


DISEASES   OF   WOMEN. 


stitches  (Nos,  10  and  11),  much  on  the  principle  of  those  made  with  a  sewing- 
machme.  A  space  of  a  centimetre  and  a  half  is  left. between  the  stitches, 
Zweifel  uses  this  latter  suture  for  the  skin.  He  does  not  use  it  for  the  fascia, 
which  he  closes  with  an  interrupted  suture. 


PLATE   XI. 


A.  B. 

A.  Showing  the  C'LosrEE  uf  the  Audomixal  Woi-xd.     (Acthok.) 

The  peritoueum  is  united  by  a  continuous  suture  of  cumol  gut.  Tlie  aponeurosis 
is  freed  from  the  rectus  muscle  at  either  side.  The  needle  is  then  made  to 
traverse  the  fascia,  take  up  a  loop  of  muscle  at  either  side  with  the  fascia 
(shown  in  the  dotted  lines),  which  is  then  perfectly  adjusted,  its  edges  in 
perfect  apposition.  The  skin  is  then  closed  with  celloidinzwirn  or  bronze 
aluminium  wire. 


B.  Closure  of  the  Fascia  by  Mattuess  Suture,  after  C.  XuBLE'r^ 

Method. 

«(.  two  iirst  sutures  tied.  Two  straight  needles  are  threaded  with  a  single 
thread — one  is  carried  through  the  fascia  from  henecdli  at  e,  and  the  tliread 
is  then  carried  over  and  made  to  pierce  the  fascia  underneath  at  the 
opposite  side;  the  other  needle  pursues  the  same  course,  the  loops  being 
placed  altematelv. 

[To  face  p.  170. 


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CHAPTER   VII. 


DISORDERS    OF   MENSTRUATION. 

Amenorrhoea  and  Leucorrhcea. 

Amenorrhoea  :   1 .  Primary,  frequently  persistent  (emansio  mensium). 
2.  Secondary,  usually  temporary  (suppressio  mensium). 

Dysmenorrhoea : — 

/Congenital  abnormalities 

Congestion  and  obstructive  congestion 

Ovaritis 

Apoplexy 

Changes  in  corpora  lutea 

Cystic  degeneration 

Cortical  and  interstitial  sclerosis 

Gonorrhoea 

Cirrhosis 

Sclerosis 
VAdhesions. 


Ovarian, 
due  to 


Tubal, 
due  to 


Uterine, 
due  to 


Congenital  abnormalities 

Inflammation 

Adhesions 

Displacement 

Strangulation 

Cystic  disease. 

Congenital  malformations 

Version  and  flexion  of  the  uterus 

Stenosis  of  the  cervical  canal 

Interstitial  fibroids 

Polypi 

Traumatic  causes  (results  of  operations) 

Endometritis. 


172  DISEASES   OF   WOMEX. 


Atresic 


Atresia  of  Fallopian  tvibe 
,,  uterine  canal 

,,  vagina 

,,  vulvar  orifice. 


Membranous  -  A  special  form  of  uterine  dysmenorrhoea. 

Menorrhagia  ;  1.  Catamenial  excess  (either  simple  excess  in  the 
normal  physiological  and  pathological  process,  or  the  result  of 
a  morbid  condition  of  the  ovaries,  uterus,  or  other  organ,  as 
the  heart  or  liver). 

2.  Climacteric  ;  occurring  at  the  menopause. 

Metrorrhag^ia :  Abnormal  flow  of  blood  during  the  intervals 
between  the  menstrual  acts. 

3.  Vicarious    (diverted) — pneumonic   (haemoptysis) ;    nasal    (epis- 

taxis) ;  gastric  (haematemesis) ;  cutaneous  (ecchymosis) ;  renal 
(hsematuria)  ;  cerebral  and  retinal ;  rectal. 

Amenorrhoea. 

(Causation.— 1.  Removable  causes  (excluding  pregnancy),  many  of 
those  cited  above  as  influencing  ovulation  and  menstruation. 
2.  Irremovable    causes — absence,   or    congenital   malformation 
and  arrest  of  development,  of  the  ovaries.  Fallopian  tubes  or 
uterus ;  acquired  disease  of  the  ovaries  or  uterus. 
We  find  that  the  commonly  occurring  causes  associated  with  a 
diminution  or  temporary  absence  of  the  menstrual  flow  are  : — 
(a)  Anaemia  and  chlorosis  ; 
(h)  Plethora; 

(c)  Some  accidental  influence  operating  on  the  woman,  as 
mental  shock,  fright,  cold,  sea-bathing  (all  these  repressing 
causes  have  a  more  decided  eflfect  if  they  occur  at  or  about 
the  time  of  a  menstrual  epoch) ;  acute  and  chronic  wasting 
diseases  ;  the  exanthemata  ; 
(d)  Congenital. 

Differential  Diagnosis  and  Pregnancy. — As  it  is  the  rule,  though 
there  are  occasional  exceptions,  that  the  menstrual  flow  ceases 
during  pregnancy,  it  is  always  our  duty,  in  any  suspicious  case, 
most  carefully  to  exclude  any  chance  of  this  condition  being  the 
source  of  the  trouble.  The  student  of  midwifery  has  already 
studied  all  the  signs  and  symptoms  of  the  pregnant  state.  He  is 
aware  how  difiicult  it  is,  before  the  uterus  rises  above  the  pubes,  to 
speak  with  any  degree  of  confidence  of  the  existence  of  pregnancy. 


PLATE   XIII. 


Utbetjs  Geayid.     Third  Month.     (,Bumm.) 

A,  decidua  serotinfe  ;  B,  chorionic  membrane  ;  C,  starting-point  of  the  decidua 

reflexa  ;  D,  uterine  cavity  ;  E,  cavity  of  the  ovum ;  F,  decidua  vera  ;  C,  G, 

decidua  reflexa  and  chorion ;    H,  lower  part  of  uterine  cavity ;  I,  cervical 

canal ;    J,   internal   os ;    K,  external   os ;    L,   enlarged  serotinal   arteries  ; 

M,  starting-point  of  decidua  reflexa. 

[To  face  p.  173. 

*^*  The  author  is  enabled  to  insert  this  photograph  through  the  courtesy  of 
Professor  Bumm,  who  sent  him  the  original  copy. 


DISORDEBS   OF  .UKX!^rnUATION. 


17:^ 


On  no  (pu-xtion  must  loe  guard  our  expressions  or  our  suspicions  more 
than  on  this,  and,  if  wr  Jiave  a  doubt,  he  careful  not  to  use  the  sound  in 
<1iatjnosl><. 

A  lady  consulted  me  to  ascertain  whether  she  was  pregnant  or  not,  as  she 
was  desirous  of  taking  a  long  holiday  trip,  and  would  not  venture  if  she  were. 
There  had  been  a  gap  of  one  month,  and  then  two  slight  periods.  She  volun- 
teered the  information  that  she  had  consulted  a  doctor,  and  he  told  her,  after 
examination  ivith  the  uterine  sound,  that  he  believed  she  was  not  enceinte. 
She  also  told  me  that  she  had  domestic  reasons  for  not  wishing  to  have  a 
child.  The  means  used  in  diagnosis  should  at  least  have  solved  for  her  this 
little  difHculty. 

Both  in  those  cases  in  which  the  possibility  of  conception  is  for 
any  purpose  concealed  or  denied,  and  in  those  in  which  the  desire 
of  the  woman  is  parent  to  the  belief,  and  she  assumes  that  she  is  or 
is  not  pregnant,  is  this  caution  necessary.  It  requires  considerable 
tact  to  avoid  committing  one's  self  to  an  opinion  until  such  a  period 
of  pi'egnancy  has  arrived  when  we  are  able  to  speak  with  confidence. 

1  do  not  enter  fully  into  the  differential  diagnosis  of  pregnancy  ;  this  is 
exhaustively  done  in  every  treatise  on  midwifery.  This  table  of  the  most 
important  proof,  divided  over  three  periods,  may  be  of  service  : — 


SECOND   PERIOD. 

Progressive  increase  in 
the  size  of  the  uterus, 
which  continues  until  the 
close  of  pregnancy,  with 
characteristic  alterations 
in  the  abdomen ;  further 
changes  in  the  breasts 
(areolae — secretion) ;  ftetal 
projections  and  heart- 
sounds  ;  ballottement ; 
placental  souffle. 


THIKD    PERIOD. 

Uterine  contrac- 
tions well  felt ;  more 
characteristic 
changes  in  the  os 
uteri  and  cervix ;  all 
the  signs  of  preg- 
nancy becoming 
more  manifest. 


FIRST   PERIOD. 

Cessation  of  the  menses ; 
reflex  and  sympathetic 
disturbances ;  changes  in 
the  breasts ;  morning 
sickness ;  enlargement  of 
the  uterus  and  altered 
position,  with  commenc- 
ing change  in  the  os 
uteri  and  cervix ;  vaginal 
signs  in  alteration  of 
colour  and  increase  of 
natural  secretion. 

Hegar's  sign  consists  in  the  uterus  losing  its  pear-shaped  outline  ;  '  the 
body  is  bellied  out  over  the  cervix  in  all  the  transverse  diameters,  especially 
autero-posteriorly.' 

It  may  be  accepted  as  a  general  rule,  to  which  we  have  occasional  excep- 
tions, that  we  are  correct  in  surmising  that  a  married  woman  in  fair  health, 
who  has  ceased  menstruating,  and  has  an  enlarged  uterus  and  softened  os 
and  cervix,  is  pregnant.  We  should  not  be  too  ready  to  be  influenced  by 
her  assertion  that  she  has  menstruated,  or,  rather,  thinks  she  has,  and  thus 
be  too  quickly  led  into  passing  the  sound.  Women  mistake  other  blood 
discharges  for  those  of  menstruation,  and  the  existence  of  pregnancy  is  not 


174  DISEASES   OF   WOMEN. 

to  be  negatived  because  a  Avoman  has  had  even  severe  losses.  I  have  known- 
the  pardonable  error  made  more  than  once  of  the  somid  being  passed  for  an 
assumed  hyperplasia,  and  abortion  follow.  In  both  cases  the  woman  ridiculed 
the  idea  of  pregnancy. 

Hegar's  Sign. — Referring  to  Hegar's  sign,  the  following  observations  of 
Charles  Noble  are  of  practical  moment : — 

'  Within  six  weeks  after  the  beginning  of  pregnancy  the  ovum  has  gi'own 
sufficiently  to  cause  the  corjDUS  and  fundus  of  the  womb  to  assume  a  distinctly 
spheroidal  shape.  As  during  this  time  the  cervix  has  altered  very  little  in 
its  form,  we  have  present,  to  make  use  of  geometrical  terms,  a  spheroidal 
body  posed  upon  a  cylinder.  If  one  will  picture  this  state  of  affairs,  he  will 
see  that  the  sphere  juts  out  from  the  cylinder  prominently  and  in  every 
direction.  In  other  words,  when  examining  the  pregnant  uterus  between 
the  sixth  and  twelfth  weeks,  the  uterus  will  be  found  enlarged  to  correspond 
with  the  period  of  the  pregnancy ;  the  corpus  and  fundus  will  be  found  as  a 
spheroidal  body,  and  the  corpus  can  be  easily  distinguished  as  jutting  boldly  out 
from  the  cervix  in  front,  behind,  and  at  each  side.  This  sign  is  of  the  utmost 
value  and  absolutely  reliable.  The  judicious  practitioner,  however,  will  not 
neglect  to  make  use  of  corroborative  signs  and  sjTuptoms.  The  spheroidal 
body  of  the  womb  wiU  be  found  softened,  and  as  it  is  held  between  the 
two  hands  in  bimanual  examination,  a  feeling  of  semi-fluctuation  can  easily 
be  made  out.  This  softening  and  the  semi-fluctuating  should  be  found  in 
all  cases.' 

In  various  abnormalities  of  the  uterus,  as  hypei-plasia,  myoma,  extra- 
uterine gi'owths,  and  in  adhesions  of  the  pelvic  viscera,  this  sign  may  be  so 
masked  as  to  be  incapable  of  detection. 

From  the  fifth  to  the  sixth  month,  in  the  great  majority  of  cases,  we  can 
speak  with  confidence  of  the  uterine  enlargement  being  due  to  pregnancy. 
Yet,  remembering  how  often  we  meet  with  such  pregnancy  complications  as 
fibroid  tumours,  ovarian  cysts,  ascites,  flatulent  distension,  or  hydramnios 
we  had  better  keep  always  before  us  the  fact  that  tlie  only  absolute  proof 
and  infallible  test  of  fregnancy  is  the  auscultatory  one  of  the  foetal  heart- 
sounds.  In  aU  the  others  a  man  may  be  deceived.  This  must  be  so,  or  we 
should  not  have  eminent  gynaecologists  committing  the  error  of  opening 
the  abdomen  for  a  tumour,  ovarian  or  uterine,  or  performing  the  operation 
of  paracentesis  abdominis  for  ascitic  accumulation,  to  find  a  pregnant  uterus. 
Nor  would  there  be  the  awkward  mistake  made  in  the  opposite  direction 
— woman,  nurse,  and  practitioner  awaiting  the  discovery  of  a  phantom 
pregnancy  and  flatulent  accumulation. 

Ansemic  and  Chlorotic  States  are  easily  recognized  in  the  pale 
conjunctiva,  the  colourless  lip  and  gum,  the  white  complexion ;  and 
in  marked  leukaemia,  the  wax-like  look  of  the  skin,  the  ansemic  first 
sound  and  functional  irregularities  of  the  heart,  the  jugular  pulse 
or  bruit,  the  pale  retina,  the  puffy  state  of  the  face  and  eyelids,  and 
the  accompanying  group  of  neuralgic  or  hysterical  symptoms  con- 
stantly associated  with  these  physical  signs.     Most  marked  of  these 


DISORDERS  OF  MENSTRUATION.  175 

are  headache,  loss  of  appetite  or  capricious  tastes  in  diet,  lassitude, 
dislike  for  outdoor  exercise,  sleeplessness,  neuralgic  pains  in  different 
places,  attacks  of  syncope,  and  a  rather  chai-acteristic  pain  referred 
to  the  left  side  of  the  chest  beneath  the  region  of  the  heart.  It  is 
in  such  a  general  depraved  state  of  the  system  that  we  are  often 
consulted.  The  watery  blood,  with  red  corpuscles  diminished  in 
quantity  and  altered  in  their  physical  characters,  does  not  respond 
to  the  demand  of  ovary  and  uterus ;  the  vitality  and  nutrition  of 
both  organs  are  lowered.  The  act  of  ovulation  gradually  ceases,  or 
may  not  occur  at  the  proper  time,  or  it  is  abortive  and  irregular, 
while  the  menstrual  discharge  is  lessened,  changed,  or  absent. 

Plethora. — Just  the  reverse  of  this  condition  is  met  with  in  the 
plethoric  and  full-blooded.  Here  there  is  a  hvpertemic  condition  of 
all  the  sexual  organs.  They  participate  in  the  general  state  of 
plethora  of  the  entire  system,  and  the  other  vital  organs.  The 
normal  balance  of  blood-supply  and  nutritive  growth  and  develop- 
ment is  lost ;  congestion  of  both  ovaries  and  uterus  results.  The 
act  of  ovulation  is  either  prevented  or  arrested  through  this  undue 
blood-supply ;  or  it  becomes  at  first  irregular  in  time  of  occurrence, 
and  in  the  quantity  of  the  menstrual  secretion,  until,  gradually 
interrupted,  it  finally  ceases.  This  type  of  case  is  easily  recognized. 
The  ready  flush,  the  high  complexion,  the  throbbing  vessels,  the 
strong  and  full  pulse,  with  accompanying  symptoms  of  headache, 
functional  heart  palpitations,  and  proofs  of  congestion  elsewhere  in 
the  lung,  kidney,  or  retina,  are  a  few  of  the  signs  that  tell  us  of 
the  cause  of  the  amenoiThcea. 

Accidental  Influences. — We  find  these  in  injudicious  habits  of 
dress,  diet,  exercise ;  in  some  mental  shock ;  in  the  sequelaa  of 
various  acute  diseases  which  have  lowered  the  vitality  of  the 
system,  or  interfered  at  the  time  of  its  occurrence  with  the 
menstrual  function.  If  we  go  carefully  into  the  history  of  any 
case  when  first  we  are  consulted,  we  can  generally  place  our  finger 
on  the  fault  which  has,  directly  or  indirectly,  led  up  to  the  cessa- 
tion of  the  menstrual  flow,  or  its  altered  character.  And  in  many 
cases  that  come  before  us  it  is  to  a  depraved  mental  condition  we 
must  look  for  the  primary  source  of  the  e-sdl. 

Congenital  Defects. — When  we  are  consulted  by  parents,  or  by 
the  patient  herself,  for  delayed  menstruation,  before  making  any 
internal  examination  it  is  well  to  enter  carefully  into  the  preWous 
history.  We  can  ascertain  if  there  has  been  an  indication  at  any 
time  of  an  effort  at  ovulation,  such  as  recurrent  j)aius  in  the  back 


176  DISEASES   OF   ^YOMEN. 

or  sides,  or.  an  attempt  at  periodical  discharge  of  any  kind ;  if  there 
be  a  general  arrest  in  development  in  the  direction  of  womanhood, 
both  physical  and  mental ;  or  if  we  can  trace  to  any  accidental 
cause  the  ai'rest  or  suppression  of  the  flow.  If  not,  we  must  keep 
before  us  the  probability  of  congenital  defects  in  ovaries,  uterus, 
and  vagina.  If  ordinary  remedies  fail  to  produce  any  effect,  a 
careful  digital  examination  in  the  presence  of  the  patient's  friend  or 
nurse  may  be  called  for.  By  its  help  we  may  decide  the  question  of 
congenital  defect.  Such  an  early  examination  is  especially  demanded 
in  young  married  women,  and  in  the  unmarried,  particularly  if  we 
have  a  history  of  old  attacks  of  vaginitis,  uterine  displacements, 
pelvic  peritonitis,  or  more  urgent  symptoms  indicative  of  retained 
menstrual  flow. 

This  would  prevent  not  only  the  serious  oversight  of  not  recognizing  the 
presence  of  morbid  growths  and  diseased  conditions  of  the  adnexa,  but  such 
awkward  mistakes  as  dosing  with  medicine  for  a  considerable  time,  and  send- 
ing to  Continental  ferruginous  spas  patients  with  congenital  absence  or  mal- 
formations of  the  genital  organs.  Prolonged  treatment  for  the  consequences 
of  atresic  conditions  of  the  uterus,  vagina,  and  hymen,  and  the  still  more 
serious  error  of  treating  a  young  girl  who  has  become  pregnant  for  gastritis 
complicated  by  amenorrhoea  are  not  such  uncommon  mistakes. 

Absence  of  the  Genitalia. 

I  have  recorded  four  cases  of  absence  of  the  internal  genitalia.  One 
occurred  in  the  instance  of  a  child,  set.  3.  Here  I  was  consulted  for  complete 
closure  of  the  introitus,  with  the  exception  of  an  extremely  small  aperture 
which  led  to  the  urethra.  The  vaginal  canal  was  found  complete.  In  this 
case  I  resected  the  fold,  closing  the  orifice,  making  a  new  vaginal  outlet. 
The  uterus  was  about  the  thickness  of  a  quill,  and  a  little  over  an  inch  in 
length,  and  there  was  complete  absence  of  the  adnexa.  The  second  case  was 
aged  22,  and  here  the  catamenia  had  never  appeared.  The  vaginal  orifice 
and  the  canal  were  normal,  but  there  was  no  evidence  of  uterus  save  a  small 
knob-like  substance  in  the  vaginal  roof,  and  under  the  deepest  anaesthesia  no 
adnexa  at  either  side  could  be  detected.  The  mammary  glands  were  quite 
rudimentary.  I  have  recentl}^  seen  two  other  cases  in  which  the  genitalia 
have  been  absent.  The  third  was  a  child,  set.  8|.  (For  particulars  of  this 
case,  see  p.  42.)  The  fourth,  a  patient,  set.  32,  consulted  me  for  severe 
pains  in  the  head  and  periodical  pain  in  the  left  side.  She  had  complained 
of  her  head  and  some  obscure  abdominal  pains  from  the  age  of  18  years. 
There  had  never  been  any  catamenial  discharge.  There  was  considerable 
mental  depression  associated  with  her  symptoms.  Sexual  instincts  appeared 
to  be  perfect,  and  there  had  been  a  question  of  marriage.  The  mammary 
glands  were  fairly  developed.  The  absence  of  catamenia,  and  some  uncer- 
tainty as  to  the  possibility  of  marriage,  had  of  late  distressed  her,  and  her 
health  had  considerably  deteriorated. 


DrSOBI)£-RS   OF  MEXsTItCATIOX. 


On  examination  under  an  anesthetic,  I  found  one  small  orifice,  which 
proved  to  be  the  uretliral.  The  clitoris  and  labia  were  perfect,  but  there  was 
no  introitus.  On  examination  by  the  rectum,  and  bi-mauually,  I  could  find 
no  uterus.  I  made  an  incision  in  the  middle  line  to  ascertain  if  I  could  light 
on  any  vaginal  canal,  and  found  that  there  was  none,  a  musculo-cellular  bed 
existing  between  the  bowel  and  the  bladder.  Complete  exploration  by  the 
opening  thus  made,  as  well  as  by  the  recto-vesical  method,  proved  that  there 
were  no  internal  genitalia.  The  patient's  position  was  afterwards  thoroughly 
explained  to  her,  and  curiously  enough  the  effect  on  her  mind  since  has  been 
most  salutary.  Her  headaches  were  proved  to  be  due  to  severe  eye-strain 
caused  by  an  old  unrecognized  and  high  hyperopic  astigmatism,  which  was 
completely  rectified.* 

Indications  for  Treatment. — These,  once  we  decide  the  cause  of 
the  amenorrhcea,  are  clear.  In  amemia — in  the  tirst  instance,  to 
restore  to  the  sexual  organs  their  normal  blood-supply,  and  correct 
the  constitutional  vice  predisposing  to  this  morbid  state ;  and 
secondly,  to  apply  to  these  organs  such  local  therapeutic  means  as 
are  calculated  to  induce  or  re-estabhsh  the  natural  performance 
of  their  functions.  We  must  correct  those  habits  that  have  a 
deleterious  influence  on  the  general  health,  and  on  the  sexual 
organs  in  pai'ticular. 

Questions  of  clothing,  diet,  exercise,  mode  of  living,  and  occupa- 
tions, have  all  to  be  carefully  gone  into.  The  use  of  warm  clothing  ; 
the  weai'ing  of  light  flannel  next  the  skin  (vest  and  drawers) ;  the 
avoidance  of  modern  devices  for  strangling  the  abdominal  and  pelvic 
viscera ;  the  securing  of  due  warmth  in  the  extremities,  both  hands 
and  feet ;  proper  support  for  the  under-clothing — all  must  be 
insisted  on.  It  is  a  good  plan  for  the  practitioner  to  give  each 
patient  her  individual  diet  table  systematically  arranged,  omitting 
all  those  articles  of  food  which  are  calculated  to  cause  or  sustain 
dyspeptic  states,  and  which  are  in  themselves  likely  to  deprave  the 
blood.  Sutflcient  quantity  of  animal  food  should  be  given,  if 
necessaiy,  in  any  of  the  forms  of  liquid  and  concentrated  foods,  or 
poultry,  game,  fish,  and  milk,  according  to  the  digestive  powers  of 
the  patient ;  moderation  in  ordering  alcoholic  stimulants  is  advis- 
able, avoiding  their  careless  recommendation  or  a  fanatical  denial 
of  their  therapeutic  value. 

Attention  to  the  times  of  meals  and  the  intervals  between  them 
is  of  equal  importance  to  their  character.  Speaking  generally,  light 
and  digestible  meals,  not  taken  at  long  intervals,  and  never  late 

*  Since  the  above  was  written  I  have  seen  a  fifth  case  of  absent  internal 
genitalia,  the  vagina  being  a  short  cul-de-sac  an  inch  hi  length.  Here  there  wa? 
decided  disordered  mentalization  and  impending  melancholia. 

X 


178  .     DISEASES   OF    WOMEN. 

Sit  night,  will  be  found  most  judicious.  We  must  correct,  when 
possible,  those  pursuits  and  their  effects  which  tend  to  corrupt  the 
blood.  Overcrowding  in  sleeping  apartments,  ill-ventilated  or  over- 
heated sitting  and  bed  rooms,  prolonged  sedentary  employment, 
much  stooping  or  standing,  excessive  study  and  long  school-hours, 
want  of  suitable  outdoor  exercise  and  amusement,  sustained  and 
violent  muscular  exercise,  as  now  frequently  taken  in  cycling,  have 
to  be  firmly  condemned. 

Decidedly  advantageous  are  those  open-air  exercises  in  which 
nearly  all  girls  at  school  have  now  the  opportunity  of  joining.  The 
one  point  for  safety  is,  that  the  degree  and  amount  of  exercise 
should  be  duly  proportioned  to  the  individual  patient.  In  certain 
instances,  especially  where  dysmenorrhoea  is  associated  with  ame- 
norrhcea,  a  full  Weir-Mitchell  course  does  good,  but  this  also  has 
to  be  carefully  regulated,  with  due  consideration  of  the  digestive 
powers,  the  nervous  susceptibilities,  and  temperament.  Not  infre- 
quently has  this  assumed  panacea  of  "  blood-making "  by  rest, 
isolation,  and  overfeeding  done  more  harm  than  good.  Like  many 
other  so-called  "  cures,"  persistence  in  its  application,  despite  evi- 
dences of  its  unsuitability,  ends  not  in  cure  but  disaster.  The 
danger  consists  in  postponement  of  surgical  measures  which  alone 
can  cure,  and  under  conditions  and  circumstances  in  which  delay 
may  be  not  alone  injurious  but  disastrous. 

Suitable  hydropathic  treatment  occupies  a  prominent  place  in 
menstrual  therapeutics.  The  iron  spa  of  which  I  have  personally 
the  most  experience  is  that  of  Schwalbach,  with  its  carbonated 
staJilhrimnen  and  weinhrunnen  springs,  which  are  most  indicated  in 
amenorrhoea  associated  with  various  forms  of  ansemia.  Spa  comes 
next,  but  there  is  something  in  the  air  of  the  Nassau  valley,  blowing 
from  the  Taunus  Mountain,  360  metres  above  the  level  of  the  sea, 
that  adds  to  the  efiect  of  the  waters  ;  also,  as  a  subsequent  resting- 
place,  Schlangenbad  is  admirable.  The  moderate  altitudes  of  both 
Spa  and  Schwalbach  are  indicated  in  anaemia.  The  more  numerous 
sources  of  the  former  give  a  larger  variety  of  water ;  and  its  bicar- 
bonate of  iron,  with  free  carbonic  acid,  is,  as  in  the  case  of  Schwal- 
bach, especially  assimilable  in  those  cases  of  chloro -anaemia,  in  which 
iron  is  often  borne  with  diificulty.  Franzenbad  and  Marienbad 
have  both  given  me  good  results ;  while,  in.  certain  cases  in  which 
arsenic  is  desirable,  the  waters  of  Royat,  in  the  Puy-de-Dome,  150 
metres  higher  than  those  of  either  Spa  or  Schwalbach,  are  scarcely 
to  be  excelled.     The  air  is  invigorating  and  stimulating,  as  are  also 


DISORDERS   OF  3lL\\.iTJ:CAJ70X.  179 


the  baths,  which  have  to  be  taken  with  caution.  These  are  the 
ferruginous  spas,  in  which  I  have  the  most  faith ;  and  if  a  course 
of  electrical  baths  be  indicated,  Wilbad-Gastein,  with  its  elevation 
of  960  metres,  its  splendid  Alpine  surroundings  and  numerous 
sources,  is  the  one  I  advise  for  selection.  In  certain  cases  where 
there  are  hepatic  troubles  complicating  disorders  of  menstruation, 
Plombieres  has  answered  admirably,  while  patients  with  renal  and 
bladder  complications  I  have  found  most  benetited  at  Kissingen, 
Marienbad,  Vals,  Vichy,  or  Vittel.  For  purely  gouty  complica- 
tions I  prefer  Carlsbad,  Contrexeville,  or  Brides-les-Bains.  At 
home  we  have  the  waters  and  baths  of  Buxton,  Bath,  Strathpeffei", 
and  Harrogate,  which  have  their  special  efficacy  in  suitable  cases  in 
which  there  are  indications  for  the  medicinal  properties  of  their 
respective  waters.  It  is  not  generally  known  that  there  is  an 
admirable  iron  spa  at  Felixstowe  in  Suffijlk,  the  analysis  of  which 
shows  that  it  corresponds  closely  to  the  Weinhrunnen  of  Sehwalbach. 
Possibly  the  waters  of  Tunbridge  Wells  are  also  not  used  as  much 
as  they  might  be,  and  I  have  found  the  Bedfordshire  Flitwick 
water  most  useful  to  administer  with  food.  Kreuznach  and  Salso- 
maggiore  are  the  foremost  absorbent  spas  on  the  Continent  for 
exudations,  old  infiltrations,  hyperplastic  conditions,  and  muscular 
degenerations,  but  they  are  not  superior  to  our  own  Woodhall  Spa, 
nor  so  convenient  of  access,  and  Kreuznach  is  very  relaxing  in 
summer. 

The  Dangers  of  Cycling. — The  rage  for  cycling  which  has  developed  among 
women  of  all  classes  within  the  last  few  years  must  seriously  affect,  according 
as  the  exercise  is  abused  or  otherwise,  their  health.  This  may  be  looked  at 
from  two  points  of  view :  either  from  that  of  its  influence  on  the  general  health, 
and  thus  indirectly  on  the  sexual  organs  and  generative  functions  of  the  woman, 
or,  more  directly  and  immediately,  on  those  organs  themselves.  Imprudence, 
both  in  the  distances  ridden  and  in  the  speed  of  riding,  impairs  the  health, 
causing  both  iiTegularity  and  in-itabihty  of  the  heart's  action,  and  inducing 
general  constitutional  weakness,  and,  in  some  instances,  anaemia.  Obviously, 
prolonged  pressure  on  the  external  genitals  must  affect  all  the  parts  from  the 
coccygeal  structures  to  the  os  pubis.  Sufficient  time  has  as  yet  hardly  elapsed 
to  enable  us  to  form  an  accurate  opinion  on  the  permanent  efifeets  that  may 
foUow  in  a  certain  proportion  of  cases  from  the  constant  use  of  the  bicj^cle. 
Many  women  of  advanced  years  now  cycle.  During  the  period  of  the 
menopause,  more  especially  if  they  suffer  from  disturbances  in  the  men- 
strual functions,  cycling  may  have  deleterious  effects,  and  should  not  he 
practised  without  advice,  certainly  never  when  there  is  a  natural  or  erratic 
period  present,  or  if  the  lieart  be  functionally  affected  or  the  patient  anaemic. 
Those  who  have  backward  displacements,  or  who  suffer  from  prolapse,  must 


180  DISEASES   OF   ^V03IEN. 

lie  careful  of  c^'cling,  if,  indeed,  they  ought  to  do  so  under  any  circumstances. 
Younger  women,  who  suffer  from  menstrual  irregularities  and  displacements, 
or  any  degree  of  prolapse,  had  better  not  ride  while  under  treatment.  There 
may  be  exceptions  to  this  rule,  but  they  must  be  regulated  by  the  individl^al 
peculiarities  of  each  case,  and  by  medical  advice.  Women  afflicted  with 
hsemorrhoids  should  not  ride.  The  young  girl  who  is  anaemic,  with  functional 
hsemic  bruit,  should  not  ride,  or  should  at  least  be  cautioned  not  to  do  so  to  the 
point  of  over-exertion  or  fatigue.     All  '  scorching '  should  be  discountenanced. 

Bathing. — Bathing  of  the  entire  body  at  a  medium  temperature 
(water  60°  to  70°  or  80°),  if  cold  be  not  well  borne,  should  be 
encouraged,  also  sea-bathing  if  it  agree,  and  if  a  healthful  reaction 
occur  after  it.  Proper  friction  is  essential,  especially  of  the  low'er 
part  of  the  back  and  the  abdomen,  after  the  bath. 

Atthill  suggested  a  plan  which  I  have  often  followed  with  success.  The 
patient  is  directed  before  she  goes  to  bed  to  sit,  protected  from  cold,  in  a 
small  bath  of  water  at  a  temperature  of  from  60°  to  70°.  The  feet  are  either 
placed  in  hot  flannel  or  in  a  small  foot-can  of  hot  water.  After  the  bath  the 
hips  and  lower  pjart  of  the  abdomen  are  well  rubbed  with  a  Turkish  towel, 
and  then  the  patient  goes  immediately  to  bed. 

Therapeutic  Remedies. — I  briefly  tabulate  the  most  important  therapeutical 
means  for  the  treatment  of  amenorrhoea  generally,  reser^ong  a  few  practical 
observations  on  some  of  the  more  useful  of  these  drugs : — 

Iron  (and  its  salts). 

Arsenic.  •  \    r^    ^  ■, 

r\  •  •  Chalybeates  general] v. 

Qumme.  '-  „      •'      ,       ^. 

-.-  .  J  Qj.      1    •        I    oeparatelv  or  m  combmation. 

jNux  vomica  and  Strychnme.  '■ 


t   In  combination  with  iron. 


Ergot  and  ergotine  ;  ergole.* 

Aloes. 

Myrrh. 

'  Celerina.' 

Aletris. 

Tincture  of  viburnum,  and  viburnum  extract. 

Borax. 

Permanganate  of  potash — Dioxide  of  manganese. 

Cannabin  tannate. 

Aletris  farinosce  extract. 

Other  Therapeutic  Means. 

Galvanism,  combined  with  properly  applied  massage. 
Internal  faradization. 
Warm  hip  and  foot  baths. 

*  '  Ergole  '  is  a  sterilized  triple  extract  of  ergot,  coutaining  2a  gra.  of  ergotin 
in  each  5  minims  of  the  fluid.  It  is  less  liable  to  cause  inflammation  in  deep 
sub-cutaneous  injection  than  ordinary  ergotin  (Oppenheimer). 


DisoiinEiiS  or  MKX^TRUATIOX.  181 


Friction  to  spine. 

Leeches  to  anus  ami  insiile  of  tliighs. 
Fomentations  to  tiie  breasts. 
Stimulating  enemata. 

Iron. — Before  adininistering  any  form  of  iron,  it  is  well  to  prepare 
the  system  for  it.  This  is  best  clone  by  the  exhibition  of  some 
gentle  saline  aperient  for  a  short  time,  such  as  a  natural  aperient 
water,  or  any  of  the  effervescing  saline  preparations  in  ordinary  use. 
For  a  few  days  before  commencing  the  iron,  an  alkaline  mixture,  of 
bicarbonate  of  potash,  or  Mindererus'  spirit  (liquor  ammoniee  acetatis) 
with  spiritus  etheris  nitrosi — the  simplest  and  best  saline  combina- 
tion of  all — may  be  prescribed.  The  diet  should  be  regulated,  and 
heavy  meals  avoided.  Farinaceous  food,  with  milk,  should  be  taken. 
Sufficient  time  should  be  permitted  to  elapse  after  meals  before  the 
iron  is  administered  ;  it  should  not  be  given  while  fasting.  The 
particular  preparation  selected  must  depend  on  the  features  of 
the  case,  or  the  tolerance  shown  for  the  exhibition  of  iron,  and  the 
exact  eflect  we  are  anxious  to  produce. 

The  preparations  I  find  most  efficacious  are  hsemogiobin  in  troches  or  syinip, 
reduced  iron,  which  can  be  given  in  pill  or  powder,  alone  or  in  combmation ; 
dried  sulphate  of  iron,  which  can  be  combined  with  quinine,  arsenic,  or  nux 
vomica  in  pill ;  the  dialyzed  solution  of  iron ;  the  compound  iron  mixture  ; 
tincture  of  perchloride  of  iron ;  the  solution  of  the  cliloroxide  of  iron  ; 
the  compound  forms,  ammonio-citrate  and  potassio-tartrate  ;  the  effervescing-, 
granular  preparations  in  combination  with  quinine ;  bromide  of  iron,  when 
we  want  iron  in  conjunction  with  the  bromides,  is  usefid.  I  have  found 
such  preparations  as  those  of  Blaud  and  Blanchard  (pills)  or  the  jelloids  of 
Warwick  borne  when  other  forms  of  iron  were  not  tolerated,*  The  syrups 
of  the  hy]oophosphites  of  iron  and  quinine.  Fellows'  and  Easton's  syrups,  or 
any  of  these  combinations,  Schwalbach,  F]itwick,t  or  Spa  Waters,  and  the 
preparations  of  ferrated  maltine  and  beef-iron  wine. 

Young  ansemic  patients  are  best  treated  by  administering  a  little  FHt- 
wick  water  with  food,  and  a  Warwick's  '  jelloid '  given  with  an  arsenic  andii'on 
pill  (in  the  fonn  and  strength  recommended  below),  about  a  quarter  of  an 
hour  after  the  meal.  St.  Raphael  wine  is  excellent  in  anaemia,  and  Steam's 
wine  of  the  alkaloidal  extracts  of  cod-liver  oil,  I  have  found  most  valuable,  a 
small  quantity  being  given  on  sitting  down  to  a  meal. 

Arsenic,  through  its  action  on  chronic  uterine  inflammatory  states, 
is  perhaps  the  most  useful  medicine  we  possess.     The  arsenious  acid 

*  The  palatinoid  form  of  Oppenheimer  is  an  admirable  method  of  giving  these 
iron  preparations.  These  palatinoids  should  not  be  given  until  almost  an  hour 
has  elapsed  after  a  meal. 

t  This  Bedfordshire  Spa  Water  is  an  admirable  chalybeate— a  tablespoonful  is 
sufficient  with  meals.     The  liq.  arsenicalis  can  be  given  with  it. 


182  DISEASES   OF   WOMEN. 

^st  ^"^  5^  ^^  ^  fjrain)  may  be  well  admiriistered  in  pill,  in  conjunction 
with  either  quinine  or  ii'on,  three  times  daily  after  food.  Fowler's 
solution,  as  a  fluid  preparation  and  capable  of  combination,  answers 
well.  The  peculiar  susceptibility  of  some  individiials  to  the  effects 
of  arsenic,  as  seen  in  irritabihty  of  the  stomach,  erythematous 
attacks  of  the  skin,  and  inflammatory  conjunctival  states,  is  not  to 
be  forgotten  when  we  are  gi^"iiig  it  for  the  first  time  to  a  patient.* 
Quinine  we  may  combine  in  administration  ■«"ith  any  medicine 
indicated  for  amenorrhcea.  It  may  be  given  either  with  arsenic  or 
iron,  aloes  and  myrrh,  ergotinej  or  nux  vomica  in  the  form  of  pill, 
or  with  various  effervescing  salts  of  iron  ;  or  the  vegetable  infusions, 
and  any  of  the  many  elegant  foims  in  which  quinine  is  now  prepared. 
The  pre2)aration  hydi'ochloride  of  quinine  can  be  conveniently 
given  with  the  tincture  or  solution  of  the  perchloiT.de  of  iron. 
Nux  vomica,  next  to  quinine,  is  perhaps  the  most  valuable  vegetable 
tonic  we  possess ;  more  especially  it  is  of  service  in  the  atonic  and 
debilitated  conditions  associated  with  suppressed  menstruation. t  It 
may  be  taken  in.  the  form  of  extract,  with  either  quinine,  arsenic, 
or  iron,  in  -g-  to  ^  grain  doses,  three  times  daily,  after  meals,  or  at 
times  combined  with  ergotine.  It  is  particularly  indicated  in  those 
sluggish  states  of  the  bowel  that  we  so  frequently  find  compKcating 
amenorrhcea.  Here  it  can  be  added  to  an  aloetic  pill.  But  the 
most  reliable  mode  of  administering  this  drug  is  as  the  liquor 
strychnise  of  the  Pharmacopoeia.  It  is  better  to  prescribe  a  stan- 
dard solution,  so  that  the  half-ounce  dose  contains  a  given  quantity 
of  the  di'ug.  With  glycerine  and  the  dialyzed  preparation  of  iron 
it  forms  an  excellent  mixture,  to  which  the  tincture  of  cj^uinine  may, 
if  we  so  desire,  be  added.  Erg'Otine,  as  an  emmenagogue,  is  a  useful 
adjunct  to  any  of  these  medicines.  It  can  be  given  (^  gr. — gr.  i. 
doses)  with  quinine  and  nux  vomica.  Ergot  and  most  other  thera- 
peutic agents  act  chiefly  as  emmenagogues.  Borax  iiL  10  gi-ain 
doses  I  have  occasionally  found  of  service.  It  is  best  administered 
by  itself  in  the  form  of  powder.  Apiol  capstdes  are  of  use,  especially 
if  there  be  dysmenorrhoea,  and  have  a  similar  action  to  ergot.  The 
recent  combination  of  apiol  and  ergot  in  capstile  form  is  an  efiicacious 

*  The  Bipalatinoids  or  pill  contains — 

Ferri  sulph.  essicc  gr.  i. 

Qurnse  sulph.  gr.  i. 

Acid,  arsenics,  gr.  jL  to  Jj. 

Ext.  micis.  vom.gr.  i. 
t  Easton's  syrup  is  conveniently  given  in  the  form  of  a  palatinoid. 


DISOIiDEIiS   OF  MEXSTRUATIOy.  183 

one.     Dioxide  of  manganese,  in  the  form  of  palatinoids,  may  be 
tried  with  advantage.     (See  below.) 

With  regard  to  the  uterine  sound,  before  we  take  it  up  to  induce  a 
menstrual  act,  ice  must  have  positively  assured  ourselves  of  the  absence 
of  pregnancy.  Seeing  the  ill  uses  to  which  it  is  put,  I  do  not  approve 
of  its  employment  as  a  means  of  treating  ordinary  amenorrhoea. 
I  am  certain  that  practitioners  have  a  more  efficacious  means  in 
electricity,  though  here,  of  course,  the  same  rule  holds  good  as 
regards  the  elimination  of  pregnancy. 

In  the  chapter  on  electro-therapeutics  various  vaginal  and  uterine  elec- 
trodes are  shown,  and  the  methods  of  using  these  are  described.  I  have 
abandoned  the  use  of  galvanic  stems.  The  difterent  forms  are  to  be  seen  in 
any  instrument-maker's  catalogue. 

If  a  galvanic  stem  be  inserted,  the  uterine  canal  must  be  sufficiently  dilated 
to  permit  of  its  passage,  and  the  stem  passed  into  the  canal  on  a  stem-inti'O- 
ducer,  either  by  the  direction  of  the  finger  or  the  aid  of  the  speculum.  The 
patient  shoidd  be  placed  in  the  semi-prone  position  and  the  duck-biU  speculum 
used.  The  uterus  may  then  be  brought  well  under  conti'ol  with  a  uterine 
hook,  and  the  stem  inserted ;  it  ought  not  to  be  long  enough  to  touch  the 
fundus.     It  should  be  withdrawn  if  pain  be  complained  of. 

Some  Special  Therapeutic  Agents. 

Aletris  Farinosa. — This  drug  will  be  found  useful  in  cases  of  associated 
amenoiThcea  and  dysmenorrhcea,  also  in  erratic  menstruation  ;  20 — 30  drops 
of  the  Uquid  extract  may  be  given  alone,  or  combined  with  tincture  of  digitalis, 
or  with  viburnum  and  caulophyllin  in  palatinoid. 

Aletris  Cordial. — This  patent  preparation  I  have  foimd  of  use  in  several 
instances,  given  either  alone  or  in  combination. 

Viburnum  Pnmifolium. — The  liquid  extract  of  Viburnum  PrunifoUum  and 
its  tincture  may  be  coml  lined  ^vith  advantage  with  both  Aletris  and  Hydrastis. 

Dioxide  of  Manganese. — This  most  valuable  medicine  for  amenorrhcea,  in 
ansemic  and  chlorotic  cases,  and  in  emansio  mensium  generally,  may  be  given 
in  gelatine  pdls,  or  in  palatinoids,  which  I  find  more  convenient.  I  give  two 
palatinoids  three  times  in  the  day  each  palatinoid  containing  grs.  ii.  of  man- 
ganese dioxide),  also  others  containing  gr.  i.  of  senecin  in  addition. 

Liquor  Caulophylla  (Pulsatilla). — I  have  tried  this  preparation  on  several 
occasions.  Its  effect  has  been  variable.  It  has  answered  well  in  some  cases 
of  dysmenorrhcea  ^ith  scanty  flow.  I  have  foimd  it  more  efficacious  when 
given  in  combination  with  •Celerina.^  I  can  recommend  this  latter  prepara- 
tion not  alone  as  an  emmenagogue,  but  as  a  general  tonic.  I  have  frequently 
given  it  with  vascular  tonics,  and  with  the  best  results.  Celerina  is  well 
administered  with  Horsford's  Solution  of  the  Acid  Phosphates,  or  the  S\Tup 
of  the  Hypophosphites,  (Celerina  contains  celery,  coca,  kola,  viburnum, 
grs.  V. — 5i.)  Liq.  caulophyllin  et  pulsatiUje  are  combined  under  the  name  of 
'  colefina.' 


184  DISEASES   OF   WOMEN. 

Santonine. — ; Whitehead  and  Hannah  found  that  santonine  in  10-gr.  doses  is 
an  efficient  emmenagogue. 

Senecio  Aureus. — This  is  a  vahiable  drug.  Its  tincture  may  be  given  in 
combination  with  other  remedies  or  the  alkaloid  senecin  in  the  form  of 
palatinoid.     These  contain  also  lupulin,  ergotin,  caulophylin. 

Massage. — INIassage  is  a  powerful  aid  to  treatment  in  amenorrhoea  and 
dysmenorrhcea.  It  may  be  general,  but  more  specially  directed  to  the  lumbar 
and  sacral  regions  or  the  gluteal  muscles.  Its  use  may  be  combined  with  the 
warm  bath  of  sea-salt  or  pine,  and  galvanism. 

Leucorrhoea. 

Of  all  terms  used  in  gynfecology,  this  one — leucorrhoea — is  em- 
ployed in  the  loosest  and  most  misleading  manner,  both  by  student 
and  practitioner.  By  leucorrhoea  we  understand  generally,  in 
practice,  what  women  call  '  the  whites.'  If  we  restrict  the  use  of 
the  term  to  simple  exaggeration  of  the  normal  secretions,  whether 
coming  from  uterus,  vagina,  or  vulva,  or  to  some  catarrhal  state  of 
the  mucous  membrane,  it  would  be,  perhaps,  correct  to  speak  of 
uterine  (corporeal  and  cervical),  vaginal,  and  vulvar  leucorrhoea. 
But  it  must  be  remembei'ed  that  simple  excess  of  the  normal  physio- 
logical secretion  rarely  continues  for  a  length  of  time  without 
inducing  pathological  changes  in  the  tissues,  which  are  quite  dis- 
tinct from  a  slight  perversion  of  simple  exaggeration  of  secretion. 
Simple  'leucorrhceal  flow'  we  meet  with,  typically,  in  pregnancy, 
in  young  girls  with  debilitated  constitutions,  and  in  those  suffering 
from  anaemia.  To  mix  up  the  idea  of  any  pathological  change  in 
the  tissues  with  ordinary  leucorrhoea  is  simply  to  lead  the  prac- 
titioner into  errors  both  of  diagnosis  and  treatment.  On  the  one 
hand,  he  may  resort  to  unnecessary  examinations,  overtreat  by  local 
measures,  apply  topical  agents  to  healthful  structures,  or  raise  un- 
necessary alai'm.  On  the  other,  he  may  be  tempted  to  pursue  an 
expectant  plan  of  treatment,  hoping  in  vain  that  he  can  control  a 
discharge  which  has  its  source  in  some  diseased  state  of  the  utei'us 
by  palliative  measures  and  general  constitutional  remedies. 

Simple  LeucorrhcBa. — In  the  table  of  discharges  is  epitomized  the 
distinctive  features  of  the  secretions  poured  from  the  uterus — body 
or  cervix — the  vagina,  and  vulva.  In  some  cases  simple  leucorrhceal 
discharge  is  very  profuse ;  perhaps  it  altogether  supplants  the 
normal  menstrual  function.  This  form  we  are  frequently  consulted 
for  in  connection  with  either  amenorrhoea  or  some  irregularity  of 
the  menstrual  flow,  and  its  accompanying  ansemic  or  chlorotic  con- 
dition.    We  also  meet  with  it  as  a  symptom  in  gouty,  rheumatic 


JilSOBDERS    OF  MEXSTBUATIOX.  185 


syphilitic,  and  tubei'cular  constitutions.  In  leuco-phlegmatic  cliil- 
tlren,  occasionally — apart  from  the  discharge  of  vaginitis — after  the 
exanthemata,  or  associated  with  worms,  and  during  dentition,  we 
find  a  true  leucorrhreal  discharge.  Though  in  anaemic  or  chlorotic 
girls  a  vaginal  examination  is  generally  unnecessary,  much  careful 
discrimination  has  at  times  to  be  exercised. 

Tliere  is  such  a  contingency  as  the  following  :  A  very  intelligent  yonng 
practitioner  brought  to  me  au  unmarried  girl  (accompanied  by  a  mamed 
sister),  sutfering  from  amenorrbcea,  with  attendant  ansemia,  gastric  sjTnptoms, 
leucon-hoea,  flatulence,  etc.  She  bad  taken  various  remedies  without  avaU. 
No  examination  had  been  made.  I  hinted  at  the  possibility  that  she  might 
be  enceinte,  but  was  assured  it  was  out  of  the  question.  The  chances  of  a 
Hexion  or  version  being  present  suggested  a  digital  examination.  I  was 
sui-prised  to  find  the  girl  far  advanced  in  pregnancy.  Insisting,  then,  on 
making  a  complete  examination,  we  were  satisfied  she  was  at  least  in  the 
eighth  month  of  pregnancy.  She  had  so  laced  and  dressed  as  to  deceive  all 
about  her,  including  lier  mother,  married  sister,  and  physician.  The  story 
tells  its  own  moral. 

When,  from  other  symptoms,  we  are  led  to  suspect  some  inflamma- 
tory condition,  or  a  version  or  flexion,  a  digital  examination  is  called 
for.  In  a  married  woman  it  is  always  the  safest  course  to  examine 
the  uterus  when  we  are  told  that  she  '  sufiers  from  the  whites.' 

Oui"  treatment  has  to  be  determined  by  the  general  aspects  of  the 
case.  The  difierent  modes  of  restoi'ing  the  general  health,  by  chaly- 
beates,  tonics,  attention  to  diet,  and  exercise,  already  pointed  out 
in  the  treatment  of  amenorrhcea,  must  be  resorted  to. 

As  to  local  measures,  we  may  do  much  by  the  vaginal  douche, 
astringent  and  alkaline  injections,  more  especially  those  of  alum, 
sulphate  of  zinc,  sulpho-carbolate  of  zinc,  borate  of  sodium,  with 
glyco-thymolin.  In  children  we  must  pay  attention  to  the  general 
health,  and  give  some  alterative,  as  small  doses  of  rhubarb,  hydrarg. 
c  creta  and  quinine  ;  also,  the  various  chalybeates — a  course  of 
syrup  of  iodide  of  iron.  Fellows'  syrup,  or  Parrish's  food.  The 
child's  diet  should  be  regulated,  and  she  should  have  proper  baths, 
sea-bathing,  and  warm  underclothing. 

Simple  uncomplicated  leucorrhoea  rarely  produces  irritation  of  the 
ATilva,  pruritus,  or  eczematous  inflammation,  while  we  frequently 
And  such  conditions  attendant  upon  vaginitis  and  discharges  of  a 
purulent  or  acrid  natui'e,  both  from  the  uterus  and  vagina.  (See 
'Vaginitis.')  Should  these  exist  in  children,  however,  scrupulous 
cleanliness  should  be  enforced,  and  the  vulvar  orifice  inspected 
regularly,  lest  there  be  any  irritation  consequent  upon  the  discharge. 


CHAPTER   YIII. 

DISORDERS    OF   MENSTRUATION  (continued). 

Dysmenorrhoea. 

Pain, — Such  pathological  states  as  congestion,  and  associated  ob- 
struction, attended  by  more  or  less  spasm,  are  constantly  met  with. 
In  a  large  gi'oup  of  cases  we  find  a  tendency  to  amenorrhoea  and 
scanty  menstruation.  The  pain  here  is  clearly  associated  with 
anfemia.  In  another  the  tendency  is  rather  to  plethora  and  con- 
gestion. So  also  the  situations  in  which  the  pain  occurs  are 
variable ;  in  the  ovarian  region,  and  along  the  inside  of  the  thighs, 
if  the  ovaries,  as  is  frequently  the  case,  should  be  the  organs  most 
at  fault ;  pain  in  the  back  and  over  the  pubes,  if  the  principal 
cause  of  the  dysmenorrhoea  be  in  the  uterus.  Reflex  pain  in  the 
head,  chest,  or  abdomen,  accompanying  the  local  pain,  is  present, 
in  some  degree,  in  most  cases  of  chronic  dysmenorrhea.  Equally 
uncertain  are  the  nature  of  the  pain  and  the  time  of  its  occurrence. 
It  varies  from  some  slight  aggravation  of  the  common  systemic 
disturbance  antecedent  to  the  menstrual  flow,  with  pain  referred  to 
the  back  or  sides,  disappearing  when  the  discharge  appears,  to  the 
indescribable  agony  which  the  friends  of  the  patient  say  '  they  can 
only  compare  to  labour  pains.'  The  pain  may  precede  the  flow, 
and  cease  as  this  commences,  or  it  may  last  all  through  the  period, 
exhausting  the  woman  physically  and  mentally.  It  is  in  such 
cases  that  the  mind  after  a  time  is  weakened,  each  period  causing 
further  prostration,  until  at  last  delirium  is  present,  or  perchance 
some  permanent  form  of  mental  aberration  results. 

Hysteria. — The  term  '  hysterical '  is  often  wrongly  employed  to  describe 
the  pain  complained  of  in  these  cases  ;  so  also  a  special  class  of  pain  is  loosely 
spoken  of  as  'neuralgic' 

Both  terms  are  apt  to  mislead  in  practice.  It  cannot  be  doubted  that  a 
large  amount  of  the  pain  complained  of  by  some  may  be  included  in  the 
general  state  known  as  hysteria,  and  with  the  type  of  pain  looked  on  as 
neuralgic.  And  it  is  likewise  true  that  the  mental  condition  of  the  woman 
leads  her  to  exaggerate  the  suffering  and  describe  it  in  extravagant  language, 


DISOlWKli^'^    OF  MEXSTRL'ATIOX.  187 

while  her  weakened  nervous  system  cannot  sustain  any  acute  or  prolonged 
pain.  This  is  still  further  accentuated  by  the  recurring  anticipation  before 
each  period.  But  if  such  considerations  influence  a  practitioner  to  regard 
any  form  of  pain  as  fanciful  or  unreal,  and  induce  him  to  look  on  his  patient 
as  '  whimsical '  and,  as  he  is  commonly  pleased  to  say,  '  hysterical ' — though 
what  he  may  mean  by  this  latter  generalization  he  would  often  find  it  very 
hard  to  explain — he  will  make  a  serious  mistake.  It  maj'^  lead  him  to  trifle 
with  the  source  of  the  disorder  in  the  ovary,  uterus,  vitiated  state  of  the 
circulation,  or  depraved  nervous  system.  It  is  the  safest  rule  in  practice 
never  to  despise  pain,  no  matter  hoiv  trivial,  and  always  carefully  to  seek  for 
the  cause  of  it.  Not  the  less  must  we  do  so  because  we  feel  convinced  that 
our  patient's  mental  powers  are  w^eakened. 

It  has  been  reported  that  women  who  have  suffei'ed  agony  from  ovarian 
dysmenorrhoea  were  completely  relieved  by  the  deception  of  an  incomplete 
oophorectomy.  When  placed  under  chloroform,  onlj-  the  preliminary  cutaneous 
incision  has  been  made.  I  have  seen  the  application  of  a  metal  disc  over  the 
ovary  relieve  ovarian  neuralgia.  Not  long  since  I  had  a  patient  who,  for 
some  time,  had  had  morphia  injected  subcutaneously  for  the  relief  of  ovarian 
and  other  pains  :  she  suffered  from  most  severe  dysmenorrhcea.  Occasionally 
she  craved  for  the  morphia.  By  the  justifiable  deception  of  seeming  to  yield 
to  her  entreaty,  while  only  pure  water  was  used,  she  had  a  good  night's  rest, 
and  expressed  herself  as  completely  relieved  the  next  day. 

We  have  no  stronger  proof  of  psychical  influence  over  physical  conditions 
than  in  the  various  applications  of  metallo-therapeutics,  and  the  strange 
eflects  of  metal  discs  applied  for  the  relief  of  hysteria  and  hystero-epilepsy. 

I  by  no  means  desire  to  be  understood  as  doubting  the  conclusions  of  the 
late  eminent  French  psychologist,  Charcot.  I  think  that  in  ocular  thera- 
peutics, and  in  the  eflects  of  the  metals  when  applied  for  various  retinal  states, 
we  have  evidence  of  the  direct  physical  results  of  metaUotherapy.  I  refer  to 
the  work  of  the  Salpetriere  physician  rather  to  impress  on  the  student's  mind 
the  double-sided  nature  of  most  ovarian  disorders.  On  the  one  side,  physical, 
from  the  slight  congestive  and  hyperaesthetic  to  the  various  pathological  con- 
ditions met  with ;  on  the  other,  psychical,  as  seen  in  all  the  so-called  hysterical 
aflections  and  states,  complicating  both  the  normal  act  of  ovulation  and  any 
abnormal  departin-e  from  the  healthful  performance  of  the  ovarian  function.* 

Charcot  originally  took  the  view  that  the  ovary  is  the  point  de  depart  of  the 
paroxysm  in  the  attack  of  hysteria  and  hystero-epilepsy — moderate  pressure 
over  the  ovary  inducing  the  aura  hysterica,  w^hile  more  energetic  compression 
arrests  it,  and  also  cuts  short  an  attack,  even  when  the  convulsions  have  com- 
menced. Pressure  is  made  and  maintained  by  the  closed  fist,  which  is  pressed 
into  the  iliac  fossa.  Grailly  Hewitt  drew  attention  to  the  fact  that  this  pressure 
also  acts  on  the  uterus,  compressing  its  vessels,  and  diminishing  uterine  con- 
gestion. He  regarded  uterine  displacements  as  having  more  to  say  to  the 
hysterical  phenomena  than  the  dislocation  of  the  ovary.  EpQeptic  fits  are  some- 
times stopped  by  pressure  in  males  in  the  inguinal  region.  This  acts  on  the 
sacral  plexus  of  nerves,  and  the  explanation  is  probably  the  same  in  some 
women . 

*  Consult  chapter  on  Oophorectomy. 


188  DISEASES   OF   WOMEN. 

From  wEat  has  been  said,  it  may  be  gathered  that  I  regard  as  of 
doubtful  scientific  accuracy  any  classification  which  has  been  made 
of  dysmenorrhcea ;  yet  here,  as  in  other  efibrts  to  classify  affections 
between  which  no  well-marked  lines  of  demarcation  exist,  we  gain 
much  in  clinical  diagnosis  and  treatment  from  the  grouping  of  ideas 
resulting  from  a  classification,  though  it  may  not  be  critically 
accurate.  Bx'oadly,  we  keep  always  in  our  mind,  in  practice,  the 
dysmenorrhoea  which  has  its  source  in  the  ovaiy  and  its  appendages 
rather  than  in  the  uterus.  The  pain  is  characteristically  ovarian, 
and  we  seek  for  congestion,  swelling,  sensitiveness,  and  displacements 
of  the  ovary.  There  may  be  adhesions  or  effusions,  and  localized 
swellings  in  the  broad  ligaments  or  Fallopian  tubes.  On  the  other 
hand,  we  may  find  on  examination,  a  satisfactory  explanation  of 
the  suffering  in  the  malformation  of  the  uterus,  in  the  congested 
€ervix,  the  contracted  uterine  canal,  some  flexion  or  version,  or  an 
inflammatory  state  of  the  mucous  membrane  of  cervix  or  fundus. 
The  relation  of  ovary  to  uterus  is  too  close  to  expect  that  this  dis- 
tinction of  ovarian  and  uterine  dysmenorrhoea  should  be  cKnically 
marked  in  a  large  number  of  cases.  Thus  we  have  the  affected 
ovary  reacting  on  the  uterus,  and  any  serious  inflammatory  affec- 
tion of  the  latter  organ  influencing  the  former.  But  we  are 
constantly  meeting  cases  of  dysmenorrhoea  in  which  we  can  detect 
210  mischief  either  in  the  ovary  or  uterus.  They  are  normal  in  size, 
position,  and  freedom  from  adhesions ;  there  is  no  fault  in  the 
patency  of  the  uterine  canal.  Here  we  must  look  to  the  circulation 
or  nervous  system  for  the  cause  of  the  pain.  This  is  traced  either 
to  the  depi'aved  quality  of  the  blood,  as  in  some  anaemic  state  on 
the  one  hand,  or  to  excessive  blood-supply — a  general  plethoric 
condition  of  the  system — on  the  other. 

Pigmentation. — The  pigmentary  changes  that  occur  contempora- 
neously with  the  menstrual  act  have  been  noticed  by  various  writers. 

Vasomotor  Coloration  of  the  Face,  with.  Pigmentary  Changes  associated  with 
Abnormal  Menstruation. — A  girl,  tweuty-two  years  of  age,  suffered  from  the 
most  severe  dysmenorrhoea  and  oophoralgia.  This  had  lasted  for  some  three 
years,  and  first  came  on  after  a  shock.  There  was  a  conical  cei-vix,  with  the 
ordinary  pinhole  aperture.  The  cervix  was  divided,  and  she  wore  an  intra- 
uterine stem  for  a  short  time.  The  operation  had  no  material  effect  on  the 
dysmenorrhoea.  Both  faradization  and  galvanism  were  tried,  also  without 
effect.  The  curious  discoloration  of  the  face  was  much  more  marked  than  in 
the  ordinary  menstrual  chromidrosis  or  pigmentation  of  the  lids.  On  two 
occasions  I  have  seen  the  cheek  ecchymosed  exactly  as  if  it  had  had  a  severe 
contusion  from  a  blow,  passing  subsequently  through  the  various  phases  of 


PLATE   XIIIj 


Vasomotob  Colobatiox  op  Face  -mTH  Pighestabt  Changes  associated 
».  viTTB.  Violent  Dysmexobehcea  and  Oophobalgia.    (Aethoe.) 

iTofacep.  188. 


DISORDEIiS   OF  MKySTllUMlOy.  189 


coloration.  The  circles  under  the  lids,  extending  below  the  malar  bones, 
often  varied  in  hue,  and  these  changes  were  frequently  very  rapid,  varying 
from  puqile  to  a  deep  greenish  black.  Sometimes  the  forehead  became  in- 
volved, and  the  whole  face  assumed  a  purplish  colour,  the  conjunctivae  sharing 
in  the  suffusion.  These  changes  generally  preceded  the  catamenial  epoch, 
becoming  intensified  during  its  occurrence,  and  disap[iearing  slowly  after  its 
close.  The  case  was  quite  distinct  from  any  I  have  previously  seen.  For 
example,  in  the  instance  of  a  lady  who  was  under  my  care  for  some  time, 
several  of  her  female  friends  thought  that  the  black  circles  were  artificially 
produced.  So  black  were  they  that  they  had  the  appearance  of  being  pro- 
duced by  Indian  ink. 

Menstrual  Congestion  of  the  Dental  Pulp. — Eegnier  *  instances  a  case  of  ii 
lady  who  had  a  carious  tooth  plugged  with  platinum,  the  pulp  being  exposed 
while  the  cavity  was  bored  out.  Eveiy  month  thereafter,  exactlj'  at  the  lime 
of  menstruation,  she  had  severe  neuralgia  in  the  aSected  tooth,  lasting  for 
forty-eight  hours.  The  only  satisfactorj'  explanation  seemed  to  be  that  there 
was  a  periodical  congestion  of  the  pulp,  causing  it  to  swell  and  press  against 
the  filling,  thus  producing  neuralgic  pain. 

Ocular  disturbances  dm'ing  menstruation  are  very  common  (see  remarks  on 
the  '  Ophthalmoscope  in  Diagnosis '  ).t  See  chapter  on  '  First  Steps  of 
Examination.' 

'  Genital  Centre '  of  the  Nose. — Schiff",!:  Fliess,  Jaw^orski,  Jwanicki, 
Chrobak,  and  others,  §  recogaizing  the  relationship  betw-een  the 
turbinal  and  the  reproductive  organs,  as  evidenced  by  various 
nasal  reflexes  occurring  during  the  catamenia  and  during  times  of 
sexual  excitation,  have  treated  dysmenorrhcea  l:>y  the  application 
of  cocaine  or  a  supra-renal  solution,  and  galvano-cauterization  of 
the  'genital  spots.'  They  have  also  used  trichloracetic  acid  to 
the  turbinals,  and  with  considerable  success.  The  dysmenorrhcea, 
especially  in  those  cases  which  were  not  dependent  on  inflammatory 
causes,  was  relieved  in  a  large  proportion  of  those  affected.  In  one 
case  in  which  I  divided  the  cervix  for  stenosis  and  secured  free 
patency  of  the  canal  without  any  effect,  cauterization  of  the 
turbinals  completely  relieved  the  dysmenorrhcea. 


Congestive  and  Obstructive  Dysmenorrhcea. 

Predisposing  Causes  of  Congestive   Dysmenorrhoea. — Plethora : 
arrested   or  suppressed   menstruation ;   inflammatory  states  of   the 

*  B^viie  Medico-CMnirgicale  des  Mai.  <1.  Femnies,  Dec,  1801. 
t  Ocular  neuralgia,  exaggeration  of  refractive  disorders,  slight  attacks  of  optic 
neuritis  and  retinitis,  etc. 
t  Sem.  M^d.,  July  16,  1902. 
§  Cox,  Brooklyn  Med.  Jon,.,  July,  1902. 


190  DISEASES   OF   WOMEN. 

uterus  and  endometrium ;  displacements  of  the  uterus ;  subinvolu- 
tion ;  fibroids ;  polyi^i. 

Symptoms. — Pelvic  pain  frequently  j^recedes  the  appearance  of  the 
menstrual  flow,  or  continues  during  the  period.  It  is  generally 
aggravated  previous  to,  and  for  the  first  twenty-four  hours  of,  the 
discharge;  the  pain  may  be  accompanied  by  constitutional  dis- 
turbance. The  uterus  may  be  found  swollen,  tender,  and  sensitive 
both  to  external  pressure  and  internal  examination ;  on  a  vaginal 
examination  with  the  speculum  we  frequently  find  the  characteristic 
and  exaggerated  discharge  of  endometritis  blocking  up,  or  hanging 
from,  the  os  uteri. 

Predisposing  Causes  of  Obstructive  Dysmenorrhoea  in  the 
Ovaries  and  Fallopian  Tubes. — Simple  congestion,  ovarian  apoplexy, 
acute  ovaritis,  morbid  changes  in  the  corpora  lutea,  cystic  degene- 
ration, cortical  and  interstitial  sclerotic  changes,  gonorrhceal  in- 
flammation, cirrhosis,  adhesions,  morbid  changes  in  the  position  or 
the  lumen  of  the  Fallopian  tube,  due  to  inflammations,  adhesions, 
strangulation  or  cystic  disease. 

In  the  Uterus. — Mechanical  obstruction  to  the  flow  of  the  men- 
strual discharge,  due  to  stenosis  of  the  cervical  canal  or  os  uteri ; 
congenital  malformations ;  uterine  displacements  which  cause  a 
narrowing  and  bending  of  the  canal,  and  which  favour  interstitial 
efiiisions  into  the  cellular  tissue  of  the  uterus,  with  resulting  hyper- 
plasia and  contraction  ;  traumatic — operative  measures  which  result 
in  stenosis  ;  polypi  and  interstitial  fibroids. 

Menge  of  Leipzig  holds  the  view  that  dysmenorrhcea  is  due  to  contractions 
of  the  uterus  consequent  upon  pre-menstrual  swelling  of  the  mucosa  and  the 
presence  of  blood.  Such  contractions  may  not  be  felt  in  health,  but  in 
hysterical  and  neurasthenic  states,  as  also  in  diseases  of  the  genital  and  pelvic 
organs,  they  become  painful.* 

Symptoms. — The  most  prominent  symptom  is  pelvic  pain,  varying 
in  intensity,  often  agonizing,  preceding  and  accompanying  the  men- 
strual discharge.  There  may  be  severe  constitutional  disturbance, 
violent  headache,  and  sickness  of  the  stomach.  The  mind  may  be 
weakened  by  the  recurring  agony,  and  delusion  may  follow,  or  the 
patient  even  become  maniacal.  Pelvic  peritoneal  symptoms  are 
frequently  present,  as  also  considerable  ovarian  irritation,  with 
pain  and  sensitiveness  of  the  ovaries  ;  neuralgic  pains  in  the  groins  ; 
attacks  of  uterine  colic  and  spasm ;  hysterical  tendencies.  Vi- 
carious haemorrhage  may  occur  elsewhere,  as  retinal  infarctions  and 
*  Central./.  Gyn.,  1901,  No.  50. 


DISOMDERS   OF  MJJXSTSrAT/O.y.  191 

effusions,  epistaxis,  liiiematemesis  or  hjemoptysis.  In  some  patients 
the  blood  becomes  depraved,  the  patient  is  aniemic  or  chlorotic  ; 
the  skin  acquires  a  yellowish-green  or  discoloured  look.  It  may  be 
that  many  of  these  symptoms  are  in  abeyance  until  the  increased 
sexual  acti^^ty  and  local  determination  and  excitement,  consequent 
upon  marriage,  react  on  both  the  ovaries  and  uterus.  Thus 
frequently  we  tind  the  tii'st  great  distress  and  pain  complained  of 
after  marriage. 


Obstructive  and  Spasmodic  Dysmenorrhoea. 

We  speak  of  'obstructive'  as  distinct  from  'atresic'" — i.e.  more  or 
less  of  mechanical  obstruction  to  the  menstrual  flow  due  to  con- 
genital or  acquired  contraction,  or  partial  occlusion  of  the  uterine 
canal  quite  apart  fi'Om  atresia  of  any  part  of  the  genital  tract, 
whether  of  Fallopian  tube,  uterus  or  vagina,  or  imperforate  hymeu. 
The  two  conditions  must  always,  both  for  etiological  and  clinical 
considerations,  be  kept  distinct.  The  congestive  and  obstructive 
forms  of  dysmenorrhoea  touch  each  other  closely,  both  from  a 
pathological  and  clinical  point  of  ^"iew.  Congestion  leads  to  obstruc- 
tion, while  impediment  to  free  flow  tends  to  congestion.  Contraction 
of  the  uterine  canal  is  a  result  common  to  the  congestion  that 
follows  a  version  and  flexion,  a  hyperplastic  eSusion,  a  growing 
fibroid,  and  an  inflammatory  state  of  the  endometrium.  More  of 
the  nature  of  an  obstacle  to  discharge  is  the  presence  of  a  small 
polypus.  This  possible,  and  indeed  probable,  cause  of  dysmenori'hcea 
is  too  often  overlooked,  and  dilatation  and  exploration  of  the  uterus 
consequently  neglected — steps  as  beneficial  from  a  therapeutic  point 
of  view  as  are  essential  from  a  diagnostic.  Traujnatic  contraction 
gives  us  the  same  results  when  it  occurs  from  operative  interference 
or  rash  therapeutical  applications. 

These  varieties  of  dysmenoiThoea  are,  I  think,  rightly  distinguished  from 
that  which  is  the  consequence  of  stenosis  associated  with  congenital  mal- 
formation of  the  uterus,  as  recognized  in  the  characteristic  conical  cervix  and 
pinhole  aperture,  or  any  of  its  varieties,  or  the  imperfectly  developed  uterus 
with  short  cervix.  Yet,  as  we  are  classifjnng  a  symptom,  and  not  a  patho- 
logical condition,  we  must  be  satisfied  to  include  this  frequently  occmring 
misfortune  under  the  heading  of  'obstructive.'  For  my  part  I  prefer  the 
classification  already  given  (p.  171). 

Thus  uterine  '  congestive  clysmenorrlicea '  would  include  simple  congestive 
conditions  and  plethoric  states ;  '  uterine  obstructive,'  such  impediments 
as    polj'pus    and    fibroid    tumours,    traumatic    contraction ;    flexions     and 


192  DISEASES    OF   WOMEN. 


versions;  inflammatory  dysmenorrhoea — endometritis  and  metritis;  cov- 
yenital  dysmenorrhoea  resulting  from  malformations  causing  atresia  or 
stenosis  of  the  os  and  cervix  ;  quite  apart  from  these  are  those  circulatorj' 
causes  found  in  anaemia,  chlorosis,  '  toxaemia '  and  other  depraved  conditions 
of  the  blood. 

In  the  classification  I  have  given  I  have  not  included  that  form 
of  dysmenorrhoea  generally  described  as  '  spasmodic' 

Every  practitioner  M'ill,  however,  meet  with  cases  of  dysmenor- 
rhoea in  which  he  can  find  no  satisfactory  reason  for  the  pain  in 
any  abnormal  state  either  of  uterus  or  ovary.  Even  if  there  be 
a  version  or  flexion,  he  finds  that  the  uterine  canal  is  pervious  ;  he 
rectifies  the  displacement,  and  still  the  pain  recurs.  There  may  be 
some  congestion  of  the  uterus,  and  ovarian  tenderness,  or  hyper- 
sensitiveness  of  the  internal  os  on  passing  the  sound,  yet  not 
sufficient  to  explain  the  violent  spasmodic  pains  that  precede  or 
accompany  the  earlier  appearance  of  the  menstrual  discharge.  We 
notice  occasionally,  as  characteristic  of  this  form  of  pain,  that  the 
patient  states  that  some  clots  have  parsed,  and  that  on  the  appear- 
ance of  these  the  pain  has  been  relieved.  The  passage  of  these 
clots  may  be  followed  by  a  profuse,  or  rather  prolonged  flow. 

1.  Is  there  such  a  distinct  cause  of  the  dysmenorrhoea  in  uterine  spasm  as 
to  warrant  our  regarding  uterine  contraction  as  a  special  form  of  painful 
menstruation,  and  either  pathologically  or  clinically  distinguishable  from 
other  forms  ? 

2.  Is  it  correct  to  assert  that  the  pain  has  its  source  altogether  in  the 
utexine  spasm,  and  not  in  the  mechanical  effects  of  congestive  closure,  con- 
traction of  the  canal  from  flexion,  or  congenital  stenosis  ? 

The  truth  of  the  mechanical  theory  of  the  pain  of  dysmenorrhoea  was 
altogether  dispiited  by  the  late  Matthews  Duncan.  His  views  may  be 
summarized  thus : — 

'  The  most  characteristic  form  of  dysmenorrhoea  is  spasmodic  ; '  it  is  '  of 
the  nature  of  a  nemosis  ; '  is  synonymous  with  neuralgic,  and  is  '  in  its  essence  ' 
due  to  '  morbid  contractions  of  the  uterus, -occurring  in  connection  with  men- 
struation.' These  contractions  are  clonic ;  they  '  come  in  pangs,'  and  when 
the  pain  is  incessant  it  is  because  the  uterine  contraction  is  tonic.  He  re- 
garded as  analogous  conditions  the  after-pains  of  pregnancy  and  spasmodic 
asthma.  He  laid  do^vn  that  '  nothing  can  be  more  erroneous '  than  the 
statement  '  that  flexion  of  the  passage  obstructs  the  discharge  of  blood.' 

He  thought  that  bad  pathology  which  regards  an  extreme  flexion  as  the 
cause  of  damming  up  of  blood  in  the  body  of  the  uterus,  and  the  usual  con- 
sequences that  follow  from  such  blood  accumulation.  The  fact  that  a  woman 
has  not  violent  dysmenorrhoea  after  the  first  two  days  of  menstruation,  as  a 
rule,  he  considered  subversive  of  the  mechanical  theory.  Its  periodicity  and 
the  influence  of  chmate  on  the  pain  still  further,  he  held,  upset  the  obstruction 
theorj'.     In  short,  he  ignored  the  influence  of  flexion,  version,  pin-point  os 


DISORDERS   OF  MENSTRUATION.  VSA 


uteri,  and  stenosis,  in  producing  the  dysmenorrhoea.  If  these  views  be  correct, 
obviously  much  of  the  luodeni  teaching  is  erroneous,  and  must  be  abandoned. 
I  have  to  confess  that  I  cannot  agree  with  them,  for  the  reason  stated  in  the 
text. 

Tliere  is  certainly  a  strong  analogy  between  the  pain  in  uterine  obstruction 
and  that  which  is,  in  the  male,  the  result  of  urethral  congestion,  strictured 
conditions,  and  gouty  urethritis.  In  the  urethra,  as  in  the  cervical  canal,  it 
is  not  necessary  that  there  should  be  any  considerable  contraction  to  produce 
spasmodic  closure.  AVe  can  pass  a  large-sized  bougie  through  the  urethra  of 
a  patient  who  a  minute  before  could  not  void  a  drop  of  urine.  The  pain  is 
the  pain  caused  by  retention  of  urine  rather  than  by  spasm.  When  we  oA^er- 
come  the  obstruction  (in  this  case  both  congestion  and  spasm)  the  pain 
disappears.  Various  degrees  of  flexion  are  doubtless  at  times  to  be  met  with 
in  women  who  have  never  suffered  from  dysmenorrhcea.  Take  such  a  case 
as  the  following  : — 

A  lady,  aged  thirty-one,  married  nine  years ;  had  two  early  abortions  shortly 
after  marriage  ;  coiituiued  regular  both  in  quantity  and  periodicity  of  discharge 
since  ;  has  never,  since  she  was  sixteen,  been  irregular,  nor  has  she  at  any 
time  suffered  pain.  Her  husband,  a  medical  man,  induced  her  for  the  first 
time  to  submit  to  an  examination  to  ascertain  if  there  existed  any  cause  for 
the  sterility.  She  was  a  highly  nervous  woman.  On  examination,  I  found 
exaggerated  anteflexion  of  the  uterus,  which  was  evidently  of  old  standing. 
The  uterus  was  not  enlarged,  nor  was  it  sensitive.  The  os  was  normal.  Here 
the  flexion  had  caused  neither  congestion  nor  obsti'uction,  nor  apparently  any 
local  derangement  of  the  uterine  nerves. 

In  men  the  irritation  of  a  goutj'  blood  cm-rent  causes  spasmodic  closure  of 
the  urethra,  and  produces  obstruction.  It  is  periodical,  and  is  relieved  by 
change  of  diet  and  hygienic  measures.  An  abnormal  condition  of  the  tissues 
and  nerves  of  a  sensitive  part  may  cause  acute  reflected  pain  elsewhere. 
Witness  severe  urethral  pain  with  hsemorrhoids,  and  remote  pains  in  the 
extremities  from  stricture  of  the  uretbra.  In  asthma,  instanced  by  Duncan, 
the  pain  or  distress  is  distinctly  induced  by  the  impeded  blood  current,  and 
we  have  to  look  altogether  beyond  the  phenomenon  of  spasm  for  the  primary 
reason  of  the  obstruction.  Doubtless  certain  uterine  conti'actions  are  painful, 
but  all  are  not  so,  as,  for  example,  those  which  occur  throughout  pregnancy, 
and  of  which  the  woman  is  unconscious.  These  are  pm-ely  physiological  ; 
they  are  not  pathological,  like  those  of  dysmenorrhcea,  or,  for  the  matter  of 
that,  like  the  after-pains  of  labour,  in  which  we  often  have  obstruction,  and 
where  there  is  a  foreign  body  to  be  expelled.  To  neither  of  these  contrac- 
tions can  we  apply  the  term  '  morbid.' 

In  those  exceptional  cases  in  which  we  can,  on  examination,  find 
no  abnormal  state  to  explain  the  dysmenorrhcea,  we  may  feel  certain 
that  it  is  for  the  simjile  reason  that  ice  have  not  been  able  to  dis- 
cover it.  The  subtle  relationship  of  ovary  and  uterus  is  sufficient 
to  account  for  sympathies  and  reflex  acts  that  we  can  find  no 
physical  explanation  of.     W^e  must  allow  that  it  is  the  exception 

o 


194  DISEASES   OF   WOMEN. 

to  meet  with  any  severe  case  of  '  spasmodic  dysmenorrhcea '  without 
some  attendant  abnormal  state  of  the  uterus  or  ovary  to  explain 
it.  Malformed  cervix,  contracted  cervical  canal,  congenitally  small 
uterus  (one  in  which  a  healthful  act  of  ovulation  fails  to  find  its 
external  physiological  expression  in  the  pi'oper  menstrual  flow), 
endometritis;  a  flexed  hyperplastic  and  hypertrophied  uterus,  or 
one  imprisoned  by  a  cellular  effusion,  and  various  abnormalities  in 
the  size,  feel,  position,  sensitiveness,  of  one  or  both  ovaries  or  tubes 
— all  are  found  associated  with  the  spasm.  For  these  and  other 
reasons,  which  I  do  not  stay  to  give  here,  I  believe  the  term 
'  spasmodic  dysmenorrhcea '  to  be  misleading  and  unscientific.  I 
still  adhere  to  the  opinion  that  spasm  is  an  accessory  symptom  in 
most  forms  of  dysmenorrhcea.  That  it  accompanies  the  pain  is  true, 
but  it  is  the  consequence  of  the  various  pathological  states  I  have 
referred  to.  And  when  we  come  to  ask  what  light  is  thrown  by 
treatment  on  the  nature  of  this  affection,  I  think  it  tends  to, prove 
the  obstructive  theory.  The  relief  afforded  by  dilatation  of  the 
canal  by  tent  or  bougie,  division  of  the  cervix,  the  posterior  section 
of  Sims,  Dudley's  operation,  galvanism,  suitable  intra-uterine  stems, 
or  such  medicines  as  apiol,  castor,  and  various  other  therapeutic 
remedies,  supports  the  older  view  that  the  spasm  is  a  consequence 
either  of  some  morbid  condition  in  the  circulatory  current  in  the 
uterus,  its  nerves  or  tissues,  or  it  is  due  to  a  congenital,  if  not 
acquired,  contraction  of  the  uterine  canal. 

In  suitable  bougies  we  have  a  ready  means  of  securing  safe  and 
rapid  dilatation  of  the  uterine  canal. 

The  bougies  I  have  devised  possess  the  advantage  over  Hegar's, 
that  from  their  shape  and  curves  they  are  easier  of  insertion  and 
manipulation,  and  the  twelve  sizes,  carefully  graduated,  meet  all 
the  wants  of  the  surgeon  (Fig.  68). 

The  time  is  approaching  when  for  all  such  cases  sea-tangle  and 
tupelo  tents  will  be  generally  discarded  for  instrumental  dilatation. 
Still,  there  are  cases  in  which  the  practitioner  may  not  feel  himself 
justified  in  resorting  to  the  force  necessary  to  dilate  a  small 
cervical  canal.  Here  aseptic  laminaria  has  to  be  first  used,  and 
subsequently  the  metal  or  other  dilators. 

General  Treatment  of  Dysmenorrhcea. — In  determining  the  treat- 
ment of  a  case  of  dysmenorrhcea,  we  must  be  guided  by  the  cause 
of  the  pain,  and  our  remedies  should  be  such  as  are  indicated  by  the 
constitutional  aspects  of  the  case,  and  any  local  fault  that  we  may 
detect.     Our  first  aim  should  be  to  correct  the  constitutional  vice. 


DISORDERS   OF  MENSTRUATION.  195 

such  as  general  plethora,  anaemia,  chlorosis,  dyspepsia,  gout,  hysteria, 
constipation,  and  those  habits  which  lead  up  to  depraAed  blood  con- 
ditions and  interfere  with  the  general  health.  Attention  to  all 
those  matters  already  referred  to  in  the  instance  of  amenorrhcea 
will  be  necessary — climate,  food,  clothing,  exercise,  and  abandon- 
ment of  injurious  amusements,  occupations,  or  morbid  excitements. 
Change  of  air,  proper  exercise,  healthful  and  regular  diet,  with 
attention  to  the  bowels,  will  cure  many  a  case  of  dysmenorrhoea 
without  further  interference.  With  an?emic  and  chlorotic  com- 
plications, the  dilierent  chalybeates  before  referred  to,  and  especi- 
ally the  combination  of  arsenic,  iron,  and  quinine,  must  be  tried. 
If  we  should  be  suspicious  of  a  gouty  diathesis  (and  '  latent  gout ' 
as  a  source  of  dysmenorrhoea  should  always  be  kept  in  view),  the 
salts  of  potassium,  lithia,  soda,  magnesia,  are  indicated,  and  these 
can  be  given  with  the  bromides  of  potassium  and  ammonium,  or 
with  colchicum  or  guaiacum.  The  pi'eparations  '  piperazaine  '  and 
'  uricidine '  are  specially  of  ser"\T^ce.  The  latter  is  a  most  powerful 
uric  acid  solvent.  The  salicylates  of  quinine,  lithia,  or  soda  (effer- 
vescing or  granular)  will  be  found  agreeable  and  useful  preparations. 
The  combination  of  the  three  bromides  of  potassium,  sodium,  and 
ammonium,  is  most  valuable.  Amongst  the  English  spas,  those  of 
Buxton,  Bath,  Cheltenham,  Harrogate  are  useful,  as  is  also  that  of 
Strathpeifer,  iu  Scotland.  The  main  point  to  be  remembered  in 
advising  a  foreign  spa  for  dysmenorrhoea  is  to  determine  the 
constitutional  vice  that  may  be  present,  and  to  select  the  waters 
accordingly.  Kissingen,  Yittel,  Plombieres,  if  there  be  gouty  states  ; 
Contrexeville  and  Yichy,  if  the  uric  acid  and  oxalic  diathesis  be 
pi'esent ;  Marienbad  and  Franzenbad  in  anaemic  and  hepatic  cases, 
Schwalbacli  and  Spa  for  anaemia  and  spansemia.  In  atonic  con- 
ditions of  the  bowels  attended  with  flatulence,  tincture  of  nux  vomica 
in  glycerine,  with  such  carminatives  as  the  compound  tincture  of 
chloroform  or  the  spirit  of  lavender,  will  frequently  relieve ;  aloin, 
nux  vomica,  and  belladonna  with  an  essential  oil,  are  at  the  same 
time  given  in  pill  form.  In  dyspeptic  cases,  if  there  be  gastric 
acidity,  the  salts  of  bismuth  in  combination  with  carbonate  of  soda, 
papaine  and  pepsine,  lactopeptine,  and  taka  diastase,  are  indicated.* 
Aperients. — For  constipated  bowels,  if  we  find  that  laxatives  and 

*  As  a  digestive  aid  in  such  cases  tbis  is  a  useful  form  :  E.  Papain,  taka 
diastase  aa  51. ;  lactopeptine,  sodii  carb.  aa  Svii.  Twenty  grains  may  be  given 
in  cachets,  or  be  taken  in  a  small  sandwich  of  bread  and  butter  at  the  close 
of  a  meal. 


196  DISEASES   OF   WOMEN. 

mild  purgatives  fail  to  operate,  the  occasional  resort  to  an  enema 
should  be  advised. 

The  pulvis  glychrrhizEe  co.  of  the  German  Pharmacopoeia,  in  doses 
of  30  grains  to  a  drachm,  may  with  advantage  be  given  as  a  mild 
but  effectual  laxative  in  the  mornings. 

Glycerine  enemata  and  suppositories  are  a  valuable  means  of 
relieving  the  bowels.  From  3SS. — ^i.  is  administered  by  means  of 
the  proper  rectal  glycerine  syringe.  It  is  convenient  to  attach  a 
narrow  rubber  tube  to  the  small  syringe,  so  that  the  patient  can 
administer  the  enema  lying  on  her  back.  I  generally  order  equal 
parts  of  water  and  glycerine,  ^ss. — ^i.  of  each.  In  some  instances 
we  have  to  abandon  glycerine  enemata  on  account  of  the  pain 
they  cause.  Frequently  they  produce  a  burning  sensation  in  the 
rectum.  Oidtmann's  purgative  is  a  suppository  of  soap,  glycerine, 
and  rhamnus  frangula.  Glycerine  suppositories  can  now  be  had  of 
any  chemist,  and  of  any  strength  desired, 

Cascara  sagrada  palatinoids  can  be  given  at  night,  a  dose  of 
Rubinat  water  being  taken  the  following  morning — three-quarters 
of  a  wineglass,  with  a  tablespoonful  of  hot  water  added.  The  liquid 
extract  of  cascara  sagrada  (liquid  extract  of  cascara,  "^i. ;  glycerine, 
^i.  ;  water,  '^y\.  (Jss.  as  a  dose))  may  be  preferred.  The  syrup 
of  figs  (Californian),  for  cases  of  slight  constipation,  acts  well,  and 
without  causing  any  griping.  Sulphovinate  of  soda  is  a  very 
valuable  aperient  for  some  women  (especially  during  pregnancy). 
A  dessert-spoonful  is  given  with  a  teaspoonful  of  syrup  of  lemon, 
and  half  a  tumbler  of  seltzer-water,  which  is  added  from  a  syphon. 
A  teaspoonful  of  psyllium  seeds  taken  at  breakfast  in  a  little  tea 
or  coffee,  and  repeated  at  luncheon  if  necessary,  is  quite  sufficient 
with  some. 

Of  the  natural  waters,  Hunyadi  Janbs,  ^sculap,  and  Eubinat  are  the 
simplest,  and,  if  they  act,  the  best  saline  aperients  we  have.  They  should 
be  taken  early  in  the  morning  in  a  little  warm  water.  Generally  a  small  cup 
of  warm  tea  or  coffee,  drunk  immediately  after,  wUl  assist  the  action.  A  mild 
alterative  or  aperient  pill  can  be  taken  the  night  before.  With  many,  a 
Tamar  confection  acts  as  an  aperient.  Habit  has  much  to  say  to  constipated 
bowels,  especially  in  women.  We  should  insist  on  a  daily  effort  being  made 
to  relieve  the  bowels,  and  often  a  drink  of  cold  water  at,  or  after,  breakfast 
will  help.  A  moist  pack,  worn  over  the  abdomen  at  night,  made  of  a  few 
layers  of  lint  ^vrung  out  of  tepid  water,  and  covered  with  an  oiled  silk  pad,  I 
have  frequently  known  to  assist  the  action  of  the  bowels.  So  far  as  possible, 
we  should  avoid  drastic  purgatives,  or  encouragement  of  the  constant  use  of 
every  variety  of '  aperient  pill.'    Brown  bread,  softer  food,  fruit  and  vegetables. 


[ 


DISORDERS  OF  MENSTRUATION.  Iii7 

\vith  some  simple  assistance,  as  the  seeds  of  psyllium,  will  generally  obviate 

the  necessity  for  so  injurious  a  custom. 

Dilatation  of  the  Sphincter  Ani. — In  many  cases  of  most  oljstinate  costive- 
ness,  in  which,  for  a  considerahle  time,  the  bowel  could  only  be  moved  V)y 
euemata,  dilatation  of  the  spliincters  under  ether  has  been  followed  by 
permanent  cure.  The  lower  liowel  is  emptied  by  an  enema,  and  washed 
out  with  boric  acid  solution.  Tlie  sphincters  are  then  dilated  with  the  hand 
in  the  manner  before  described.  After  the  rectum  has  been  washed  out,  an 
enema  of  salad  oil  is  administered.  This  is  repeated  the  next  morning,  and 
the  patient  is  given  nightly  a  pill  of  nux  vomica,  belladonna,  and  cascara. 
The  dilatation  may  be  assisted  by  a  galvanic  current  used  over  the  course 
of  the  colon  daily.*  This  is  well  supplemented  by  abdominal  massage, 
administered  in  the  knee-elbow  position  in  the  course  of  the  colon,  the 
masseuse  operating  from  behind. 

Sedatives  and  Hypnotics. — If  the  pain  be  refei-red  particularly 

to    the  region  of    the   ovaries,   and    assume  a  neuralgic   type,   the 

bromides  of  sodium,  potassium,  and  ammonium  are  indicated.     An 

excellent  combination  is  that  of  bromide  of  potassium  (gr.  xv.),  and 

hydrate  of  chloral  (gr,  xii.),  given  at  intervals  of  four  hours  when 

the  pain  is  felt.     An  enema  of  chloral  and  bromide  of  potassium  will 

be  found  of  ser^dce.     Tincture  or  extract  of  cannabis  indica,  tannate 

of    cannabin,   humulus    lupulus,  castor,   lupuline,   monobromate   of 

camphor,  apiol  (in  capsules),  nepenthe  or  codeine  at  night,  or  the 

subcutaneous  injection  of  moi'phia,  are  all  of  use  to  subdue  the  pain. 

The   '  aletris  cordial,'   '  liquor   sedans,'   and    '  celerina  '   are  valuable 

combinations  ;  the  first,  combined  with  other  uterine  haemostatics, 

in  menorrhagia  ;  the  second,  for  the  pain  of  dysmenorrhcea  ;  and  the 

third,  as  a  useful  tonic  which  can  be  given  with  iron  and  other 

preparations  to  those  who  are  debilitated    by  excessive    losses   or 

suffering.     Indispensable  in  those  cases  both  of  amenorrhcea  and 

dysmenorrhcea    in  which  we    have  cardiac    irregularity,  enfeebled 

action,  mitral    stenosis    (or    at    times    in    aortic    stenosis),    in    the 

absence  of  compensation,  are  the  vascular  tonics,  strophanthus  and 

digitalis.     They  can   be  given   in   menorrhagia  and   metrorrhagia 

with  hydrastis  and  ergotine.     Digitalis  has  the  great  advantage  of 

its  action  in  producing  contraction  of  the  arterioles,   and  is  well 

given  with  the  tinctures  of  aletris,  viburnum  or  hydrastis,  and  with 

'  ergole  '  or  sclerotic  acid.     Some  of  the  legion  of  preparations  of  the 

coal-tar  series  may  be  tried — antipyrin,  antifebrin,  'analgen,'  'anti- 

kamnia,' '  ammonol,'   all  have  been  used  with  varied  success.     Sul- 

phonal  and  trional  are  most  valuable  hypnotics,  and  in  hysterical 

*  The  20-cell  battery  of  the  Silvertown  Company,  London,  is  the  best  for 
daily  use.     It  lasts  without  any  need  for  renewal  for  one  or  two  years. 


198  DISEASES   OF   WOMEN. 

cases,  as  a  rule,  produce  sleep.  A  suppository  of  trional  is  an 
admirable  method  of  administering  the  drug  (each  containing  fifteen 
or  twenty  grains).  Chloralamid,  in  doses  of  twenty  to  thirty  grains, 
has  many  advantages  over  other  hypnotics ;  it  has  no  after-effects. 

Paraldehyde  *  in  drachm  doses  may  be  given  in  dysmenorrhoea, 
or  urethrane  in  twenty  to  thirty  grain  doses ;  but  though  useful  as 
hypnotics,  they  have  little  effect  in  relieving  pain. 

Thryoid  Extract. — Thryoidine  has  been  given  with  good  results  by  Stinson, 
who  regards  it  as  a  uterine  aud  ovarian  anodyne  having  a  specific  action  on 
the  vasculo-motor  nerves  of  the  uterus  and  ovaries.f 

The  Morphia  Habit. 

Hysterical  and  Neuralgic  Cases. — Abuse  of  Morphia  Injections. — There  is  a 
strong  objection  to  resorting  to  the  subcutaneous  injection  of  iaoi"phia  in 
hysterical  women  if  we  can  possibly  avoid  doing  so.  Often  a  habit  or  craving 
is  encouraged,  with  all  its  pernicious  consequences,  and  the  symptoms  of 
morphiomania  may  be  developed.^ 

The  neurotic  and  Ij'mphatic  temperaments  have  been  proved  by  all 
observers  to  be  those  most  susceptible  to  the  toxic  effects  of  the  drug.  So 
far  as  its  action  on  the  catamenia  is  concerned,  morphia  used  habitually  has 
a  tendency  to  arrest  menstruation,  and  sterility  is  often  a  consequence.  If 
otherwise,  there  are  its  bad  effects  on  the  embryo  to  be  considered.  One  fact 
of  the  greatest  importance  stands  out  clearly  in  regard  to  morphiomania,  viz. 
that  the  '  hysterical '  temperament  is  the  one  occupying  the  foremost  place  in 
its  causation.  Hysteria,  neurasthenia,  neuralgia,  cephalalgia,  ovarian  crises, 
spinal  neuropathies,  dysmenorrhoea,  neuromimesis,  are  the  correlated  con- 
ditions, often  associated  with  sexual  disturbances,  which  stand  in  the  fore- 
front of  the  etiology  of  morphia  abuse  in  women.  And  they  are,  unfortu- 
nately, the  very  conditions  for  which  it  is  most  frequently  prescribed. 

Neurotic  women  are  distinctly  those  that  all  experience  has  proved  are 
most  likely  to  be  conquered  by  the  physiological  action  of  the  drug.  They 
are  always  importunate  for  its  emploj'ment,  once  they  have  experienced  its 
effects,  and  the  weak-kneed  physician  is  compelled  to  yield  to  their  impor- 
tunity. A  prescription  is  given,  possibly  a  nurse  is  entrusted  with  the 
administration,  and  very  frequently,  when  the  nurse  leaves,  the  patient, 
retaining  the  prescription,  not  only  administers,  but  practically  prescribes,  the 

*  The  disagreeable  taste  of  the  drug  may  be  obviated  by  giving  it  in  palatinoids  : 
each  contains  five  minims  of  paraldehyde.  SuliDhonal  may  be  administered  in 
the  same  manner. 

t  Amer.  Jour.  Obst.,  July,  1902. 

X  At  the  British  Gynsecological  Society,  March  li,  1895,  the  author  brought 
the  subject  of  the  abuse  of  morphia  iu  gynsecological  practice  forward  for 
discussion.  He  then  entered  fully  into  the  influence  of  temperament  on  its 
action  and  effects ;  its  physiological  and  psychical  influences,  and  the  precau- 
tions to  be  observed  in  its  exhibition. 


DISORDERS   OF  MENSTRUATION.  199 


medicament  for  herself.  I  have  known  a  supply  of  two  ounces  of  a  morphia 
solution  of  the  British  Pharmacopceia  obtained  daily  at  diffei'ent  chemists', 
and  thus  as  much  as  eighteen  to  twent}'  grains  of  nioi"phia  have  been  taken 
subcutaneously  within  the  twenty-four  hours. 

Many  of  the  atVections  of  women  which  specially  fall  to  the  lot  of  the 
gynaicologist  to  treat  are  of  a  reflex  nature,  arising  out  of  disorders  of  the 
uterus  and  its  appendages,  and  are  to  be  cured  only  by  the  restoration  to 
health  of  the  deranged  pelvic  organ.  In  the  majority  of  such  cases  the 
morphia  syringe  is  the  most  mischievous  remedy  to  resort  to.  It  may  bridge 
over  a  period  of  time,  but  often  this  gain  is  achieved  at  the  expense  of  the 
entire  moral  control  of  the  woman,  and  her  latent  power  to  endure  even 
trifling  pain. 

Categorically  summarizing  the  different  methods  of  curing  the  morphio- 
maniac  or  morphinises,  there  are — 

(o)  Lewistein's  method  of  '  abrupt  suppression,'  or  sudden  stoppage  of  the 
morphia ;  this  has  been  found  to  be  dangerous,  and  did  not  answer. 

(&)  The  plan  (Erlenmej'er)  of  gi-adual  suppression,  or  reducing  the  doses 
of  morphia  hj  degxees,  and  extending  this  over  some  time. 

(c)  The  medium  course  of  moderate  suppression — or  stopping  the  morphia 
gi"adually  in  the  course  of  some  eight  to  ten  days.  This  plan  may  be  com- 
bined with  the  use  of  various  hypnotics.  In  one  case  of  the  author's  urethrane 
answered  well. 

id)  Alcohol  has  been  tried  as  a  substitute  for  the  moi-phia.  This  has 
failed. 

(e)  Chloral  also  has  been  tried  and  abandoned. 

(/)  Opium  itself  has  been  tried,  and  other  of  its  alkaloids,  but  they  have 
not  answered. 

{g)  Nitro-glycerine  and  other  drugs  have  been  given. 

Qi)  Subcutaneous  injections  of  atropine  have  been  employed  by  W.  Kochs, 
of  Bonn,  as  an  antidote  to  morphinism,  to  diminish  the  unpleasant  results  of 
abstinence. 

(i)  Heroin  in  combination  with  codeine  and  strj^chnine  subcutaneously. 

The  treatment  by  moderate  suppression,  combined  with  judicious  control, 
diet,  and  the  use  of  hypnotics,  is  the  best  plan  to  adopt.  Atropine  is 
combined  with  the  morphia,  which  is  reduced  gradually,  while  codeine  is 
given  by  the  mouth,  and  strychnine  at  intervals  subcutaneously.  There 
is,  however,  a  danger  in  deceiving  the  patient  by  the  substitution  of  water 
for  morjohia,  as,  once  discovered,  it  is  apt  to  lead  to  a  sense  of  indignation 
on  her  part,  and  a  refusal  to  be  again  guided  by  her  physician. 

Galvanism. — Locally,  benefit  may  be  derived,  from  the  constant 
current :  10  to  15  cells  of  Leclanche's  battery  may  be  applied 
daily.  A  pigment  of  iodine  with  belladonna  or  a  combination  of 
chloroform  (5  iv.),  extract  of  belladonna  (5  ii.),  tincture  of  aconite 
(5  iv.),  camphor  (3  ii.),  mastich  (5  iii.),  rectified  spirit  (^  i-),  laid 
on  with  a  brush  over  both  ovaries,  is  a  most  eff'ective  application, 
or  vesication  over  the  ovary  with  a  little  chloroform  applied  on  a 


200  DISEASES   OF   WOMEN. 

watch-glass.  But  in  every  case  of  so-called  '  neuralgic  '  dysmenor- 
rhcea,  we  must  seek  further  than  the  situation  of  the  local  mani- 
festation for  the  cause  of  pain.  In  the  intervals  between  the  periods, 
the  closest  attention  must  be  paid  to  the  general  management  of 
the  case  ;  any  constitutional  defect  has  to  be  rectified  ;  tonics  should 
be  given,  such  as  quinine,  arsenic,  bark,  minerals,  acids,  strychnine, 
nux  vomica,  or  the  salts  of  zinc  ;  chalybeates  if  the  patient  be 
ansemic ;  salines  and  mineral  aperient  waters  if  the  tendency  be  to 
plethora. 

Hysteria. — The  hysterical  temperament  has  to  be  met  by  such 
remedies  as  the  bromides,  in  combination  with  valerian,  assafcetida, 
or  galbanum.  Much  may  be  achieved  by  correcting  errors  of  diet 
and  abuse  of  stimulants,  by  attention  to  exercise,  and  by  giving  the 
mind  healthful  occupation  with  such  agreeable  outdoor  recreation  as 
circumstances  will  permit,  or  a  course  of  massage  with  the  Weir- 
Mitchell  diet  and  regimen. 

It  is  in  these  cases  before  all  others,  iinless  they  be  absolutely  demanded  by 
some  local  condition,  that  we  should  discountenance  vaginal  examinations, 
the  use  of  the  speculum,  and  uterine  manipulations.  If  in  the  unmarried 
girl  there  be  a  leucorrhoeal  discharge  during  the  intervals  between  the 
periods,  in  a  large  proportion  of  cases  it  will  disappear  with  appropriate  treat- 
ment, aided  by  the  vaginal  douche  of  hydrastis,  borax,  alum,  sulphocarbolate  of 
zinc,  carbonate  of  soda,  or  permanganate  of  potash.  Should  it  not  do  so,  or  if 
in  the  first  instance,  from  the  severity  of  the  symptoms  or  their  persistence, 
we  are  suspicious  of  local  disease  or  abnormality,  an  examination  should  be 
made.  I  repeat  that  such  a  step  is  not  to  be  unnecessarily  advised  or 
needlessly  persisted  in. 

The  same  remark  applies  to  those  cases  of  married  women,  found  floating 
about  in  such  numbers,  who  have  been  to  this  doctor  and  that,  who  flippantly 
detail  all  the  therapeutic  means  known  for  the  cure  of  sterility  and  dysmenor- 
rhoea,  and  appear  to  have  exhausted  the  resources  of  imagination  and  art. 
The  womb  has  been  'slit,'  '  cut,'  'stretched,'  'replaced,'  'depleted,'  not  by 
one  medical  adviser,  but  by  two  or  three ;  yet  they  are  none  the  better,  but 
infinitely  the  worse,  mentally  and  physically,  for  all  this  ingenious  exercise  of 
manipulative  skill.  To  restrain  a  woman  from  healthful  intercourse,  with 
proper  intervals  of  rest,  while  she  is  made  the  victim  of  exhaustive  vaginal 
explorations  and  pessary  adjustments,  is  neither  just  nor  reasonable.  Erotic 
tendencies  are  sustained,  and  the  whims  and  fancies  of  hysteria  are  en- 
couraged. 

In  plethoi-ic  cases  we  derive  benefit  from  salines,  the  various 
saline  waters,  occasional  aperients,  and  close  attention  to  diet  and 
exercise.  Iron  has  to  be  carefully  avoided.  We  can  cleanly, 
quickly,  and  efliciently  deplete  the  uterus  with  the  uterine  lancet. 


DISORDERS  OF  MENSTRUATION.  201 


Digitalis,  with  bromide  and  iodide  of  potassium,  is  a  useful  com- 
bination, or  the  tincture  of  strophanthus  may  in  many  cases  be 
substituted  for  that  of  digitalis  with  advantage.  In  iheumatic  and 
gouty  patients,  salophen,  aspirin,  salol,  colchisal,  piperazaine  (in 
combination  with  guaiacum)  may  be  tried. 

The  administration  of  a  pill  containing  lupuline,  ergotine,  extract 
of  cannabis  (of  each  gr.  i.),  taken  three  times  daily,  alternating  it 
with  a  mixture  of  bromide  of  potassium  and  chloral,  is  of  service. 
In  such  obstinate  cases  we  must  be  particularly  careful  in  the  use 
of  stimulants.  It  is  far  better  to  insist  on  the  total  relinquishment 
of  all  alcoholic  drinks.  If  the  patient  cannot  be  induced  to  abandon 
theui,  we  had  better  recommend  some  light  wine,  as  claret,  hock, 
or  sauterne. 

The  local  means  of  combating  dysmenorrhoea  will  be  determined 
according  to  the  state  of  the  uterus  with  which,  on  examination,  we 
find  it  associated.  There  may  be  a  version  or  flexion  requiring 
rectification,  and  the  application  of  a  suitable  pessary.  The  canal 
of  the  cervix  may  be  contracted,  necessitating  dilatation  of  the  canal 
with  uterine  bougies.  We  can  in  a  few  days,  commencing  with  the 
bougie  of  11  millimetres,  increase  to  30  millimetres.  If  the  stenosis 
be  extreme,  and  the  cervix  conical,  the  best  course  will  be  to  prepare 
our  patient  for  the  division  of  the  cervix,  and  to  perform  this 
operation  about  ten  days  after  the  menstrual  period  has  ceased. 
After  division,  the  celluloid  stem  may  be  worn  for  a  short  time 
(Fig.  116). 

The  remedies  already  recommended  in  certain  forms  of  dys- 
menorrhcea  associated  either  with  amenorrhcea  or  monorrhagia, 
piscidia,  hydrastine  hydrochloride,  cornutin,  cimicifuga,  viburnum, 
apiol,  caulophillum,  aletris  farinosa,  monobromate  of  camphor,  are 
those  most  generally  employed  for  the  relief  of  the  pain.  They 
should  be  tried  in  combination.  The  preparations  '  aletris  cordial ' 
and  that  known  as  '  liquor  sedans '  are  very  efficacious  in  subduing 
pain  in  some  cases.  In  those  which  are  clearly  of  the  neuralgic 
type,  phenacetin,  '  antikamnia,'  antifebrin,  ammonol,  will  often 
give  relief,  especially  when  there  are  also  neuralgic  pains  in 
the  groins  and  thighs.  Oxalate  of  cerium  has  been  given  with 
benefit.  Inflammatory  states  of  the  endometrium,  should  they  be 
present,  must  be  treated.  When  any  polypus  blocks  the  passage, 
or  a  uterine  fibroid  obstructs  the  flow,  each  has  to  be  specially  dealt 
with.  The  woman's  life  is  often  rendered  miserable  by  these  re- 
current  attacks  of   pain   and    intolerable    suflering.      When  other 


202  DISEASES   OF   WOMEN. 

means  have  been  exhausted  witliout  any  benefit,  we  should  consider 
the  advisability  of  removal  of  the  adnexa,  placing  fairly  the  exact 
nature  and  risks  of  the  operation  before  our  patient. 

In  those  cases  in  which  the  pain  precedes  the  menstrual  flow,  and 
is  characteristically  ovarian,  with  sensitiveness  and  fulness  in  the 
ovary  at  either  side — a  fulness  which  can  generally  be  felt  through 
the  vaginal  roof  or  rectum — depletion  of  the  cervix  or  leeches  applied 
either  in  the  region  of  the  ovaries  or  near  the  anus,  vesication  over 
the  iliac  region,  warm  sitz-baths,  full  doses  of  bromide  of  potassium 
or  ammonium — are  among  the  best  means  of  obtaining  relief. 

The  Weir-Mitchell  Treatment. 

Splendid  results  in  these  pitiable  cases  of  chronic  ovarian  excitement,  with 
various  neurotic  troubles — insomnia,  loss  of  appetite,  wasting,  morbid  fancies, 
and  numerous  reflex  pains — may  be  obtained  from  Weir-Mitchell's  plan. 
The  principles  of  his  treatment  are  :  1.  Eest  and  seclusion  of  the  patient. 
This  includes  the  exclusion  of  officious,  meddling,  and  over-sympathetic 
friends ;  the  assistance  of  an  intelligent,  refined,  firm  and  judicious  nurse  and 
companion.  If  there  be  retroversion  of  the  uterus,  the  patient  is  kept  as 
much  as  possible  in  the  prone  or  face  position.  This  rest  treatment  must  be 
continued  for  some  weeks.  2.  Change  of  diet.  This  consists  in  feeding  the 
patient  with  a  light  but  nutritious  and  moderately  stimulating  diet,  much  in 
excess  of  the  demand  necessitated  by  the  daily  waste — principally  milk  at 
repeated  intervals ;  soups ;  malt  preparations  (Horlick's  malted  milk  vnll  be 
found  an  admirable  remedy) ;  a  wine,  such  as  burgundy,  hock,  dry  champagne  ; 
and  other  generous  diet.  3.  The  administration  of  iron.  4.  The  use  of  mas- 
sage and  electricity,  a  skilled  masseuse  carrying  out  the  massage  for  the  space 
of  half  an  hour  to  an  hour  once  or  twice  dady.  Cocoanut  oil  is  employed  to 
assist  the  massage.  The  constant-current  battery  is  used,  or  a  mild  Faradic 
current  applied  over  Ziemssen's  points.  Lastly,  this  treatment  may  be  sup- 
plemented after  a  time  by  the  use  every  morning  of  a  tepid  spinal  douche, 
while  the  patient  sits  on  a  stool  in  a  bath-tub  with  her  feet  in  warm  water. 
The  water  is  poured  over  the  back  at  a  temperature  of  80°,  and  is  reduced 
one  degree  daily,  until  it  is  brought  to  the  ordinary  temperature.  Suitable 
friction  follows  the  douche,  the  patient  dressing  rapidly  and  after  some  food 
taking  a  brisk  walk,  which  should  not  be  of  sufficient  length  to  exhaust  her 
strength  or  tire  her. 

In  the  guidance  of  a  Weir-]\Iitchell  case  we  must  be  influenced  by  the  indi- 
cations present  in  each  individual  patient.  It  is  not  prudent  to  hold  hard- 
and-fast  rules  left  to  the  discretion  of  a  nurse  in  every  case.  Temperament, 
powers  of  assimilation,  capacity  to  digest  milk,  and  the  effects  of  isolation, 
have  to  be  regulated  for  each. 

'  The  patient  should  be  weighed  before  being  put  to  bed,  and  at  frequent 
intervals  during  the  treatment.  She  is  first  placed  on  a  milk  diet,  and  for  the 
first  day  or  two  from  three  to  four  ounces  are  given  every  two  hours.  The 
milk  may  be  slightly  warmed,  and,  if  it  be  particularly  distasteful  to  the 


DISORDERS  OF  MENSTRUATION.  203 

patient,  may  be  flavoured  with  a  little  tea  or  coffee.  The  quantity  is 
gradually  increased,  and  the  intervals  lengthened  to  three  hours,  till  at  last 
two  quarts  are  taken  in  the  twenty-four  hours.  Tliis  rest  in  bed,  and  the 
simple  milk  diet,  "  nearly  always  dismiss,"  says  Weir-Mitchell,  '"  as  if  by 
magic,  all  the  dyspeptic  conditions  "  from  which  the  patient  had  previously 
suffered.  The  circulation  is  at  the  same  time  stimulated,  and  the  muscles 
undergo  passive  exercise  by  being  kneaded  by  massage  and  moved  by  electric 
currents.  The  bowels  are  carefully  regulated.  After  from  four  to  seven 
days,  a  little  solid  food  is  taken,  namely,  bread  and  butter  for  breakfast,  and 
a  milk  padding  for  dinner.  A  day  or  two  later,  fish  and  chicken  or  a  mutton 
chop  are  added,  first  either  to  the  mid-day  or  evening  meal,  and  then  at  both. 
In  about  ten  days  the  patient  is  put  on  three  full  meals  daily,  and  the  diet  is 
as  follows : — 

'  Milk — sixty  to  eighty  ounces. 

'  Breakfast — poiTidge  and  cream. 

'  Second  breakfast — cocoa  and  egg,  bread  and  butter. 

•Luncheon — fish,  bread,  pudding,  and  milk,  or  chicken,  vegetables  and 
pudding. 

'  Dinner — mutton  or  other  digestible  meat,  two  or  three  kinds  of  vegetables, 
milk  pudding,  or  stewed  fruit  with  cream. 

'  Extract  of  malt  may  be  given  with  one  or  more  of  the  supplies  of  milk, 
and  in  some  cases  cod-liver  oil  is  also  prescribed.'  * 

Membranous   Dysmenorrhcea. 

This  is  not  a  common  affection.  Here  we  bave  exfoliation  of  the  uteiine 
mucous  membrane,  either  in  the  form  of  shreds,  or  sometimes  as  a  complete 
cast  of  the  uterine  cavity  in  which  are  the  orifices  of  the  Fallopian  tubes  or 
OS  uteri.  A  patient  of  the  author's  before  marriage  passed  these  casts  of  the 
uterus,  and  this  continued  for  the  first  year  after  marriage.  The  little  mem- 
branous exfoliation  preserved  completely  the  form  of  the  uterine  cavity.  The 
affection  yielded  in  time  to  treatment ;  she  became  pregnant  and  had  a  family. 
This  form  of  dysmenorrhcea  is  not  necessarily  related  to  conception.  It  does 
QOt  of  necessity-  cause  sterility,  though  as  long  as  the  aflection  persists  it 
predisposes  to  this  condition.  Microscopically,  the  membranous  layer  is 
found  to  be  composed  of  connective-tissue,  glands,  and  deciduous  cells. 

In  two  cases  reported  by  Mansell-MouUin,  the  structure  of  the  membrane 
was  shown  to  consist  of  '  large  fusiform  and  rounded  cells,  many  of  which 
appeared  to  have  two  nuclei,  as  if  undergoing  proliferation,  containing 
utricular  glands  lined  with  columnar  epithelium  of  large  size,  and  numerous 
blood-vessels  of  different  calibre.' 

The  passage  of  the  membrane  is  not  always  accompanied  by  pain. 
There  is  frequently  associated  with  the  dysmenorrhcea  endometritis. 
We  must  not  confound  this  membranous  cast  with  an  exfoliation  or 
a  blood-coagulum.  The  microscope  and  a  little  care  will  prevent 
this  error.  Hitherto  neither  the  abortive  evolution  theory,  nor  any 
*  Mrs.  Ernest  Hart,  'Diet  in  Sickness  and  Health.' 


204  DISEASES   OF   WOMEN. 

other,  has  satisfactorily  explained  the  causation  of  this  affection. 
If  we  hope  to  alter  the  character  of  the  menstrual  act  radically,  we 
tQust  change  the  nature  of  the  uterine  mucous  membrane.  The 
most  energetic  treatment  consists  of  dilatation  of  the  uterus,  the 
use  of  the  curette,  and  the  subsequent  application  of  chromic  acid 
to  the  endometrium.  Inflammatory  complications  should  be  sub- 
dued if  they  exist.  The  interior  of  the  uterus  should  be  treated 
during  the  intervals  between  the  periods  by  such  remedies  as  fused 
nitrate  of  silver  or  sulphate  of  zinc  points,  iodized  phenol,  ichthyol, 
or  carbolic  acid.  If  the  pain  be  severe  during  the  separation  of  the 
membrane,  chloral  and  bromides,  opiate  suppositories,  vaginal  pessa- 
ries of  belladonna  and  morphia,  or  morphia  injected  subcutaneously, 
will  give  relief.  Coitus  should  not  be  allowed  while  the  patient  is 
under  treatment. 

Electrolysis  in  Dysmenorrhoea. — Dilatation  bj^  electrolysis  has  answered  well 
in  several  reported  cases.  The  positive  rbeophore  is  placed  over  the  abdo- 
men, and  the  negative  electrode  is  introduced  into  the  uterus  through  the 
internal  os.  The  sitting  lasts  from  ten  to  twenty  minutes.  Six  small 
Leclanche  cells  are  used. 

Menorrhagia. 

In  dealing  with  any  case  of  excessive  flow  of  blood  from  the 
uterus  some  bi'oad  practical  rules  have  to  be  remembered. 

1.  Never  neglect  nor  trifle  with  an  unusual,  continuous,  or  ex- 
aggerated loss  of  blood  from  the  uterus,  by  palliative  measures. 

2.  Always   remember  that   the  haemorrhage  is  but   the  sign  of 

some  abnormal   condition    elsewhere,   or   of   disease   in   the 
uterus  itself. 

3.  In  case   of  douht  make   a  careful  vaginal  examination  ;  should 

this  not  explain  the  cause,  and  the  hsemorrhage  continue,  dilate 
the  uterus  and  explore  its  cavity. 

4.  Once  the  cervix  is  dilated,  maintain  a  certain  degree  of  dila- 

tation, as  long  as  the  discharge  of  blood  continues. 

The  local  conditions  most  frequently  met  with  which  cause 
haemorrhage  are  :  fibroid  tumours,  subinvolution,  endometritis  and 
cervicitis,  morbid  conditions  of  the  endometrium,  products  of  con- 
ception in  utero,  erosion  of  the  external  os  and  cervix,  granular 
states,  malignant  disease,  polypus,  and  uterine  congestion  associated 
with  flexion,  and  ovarian  congestion. 

Our  treatment  may  be  divided  under  two  heads :  (1)  Attention 


DISORDERS   OF  MENSTRUATION. 


205 


to  any  organic  disease  in  the  heart,  lungs,  liver,  spleen,  kidney  ;  the 

control  of  excessive  discharge  during  the  exantliemata,  in  purpuric 

states,  at  the  climacteric  period,  or  after  prolonged  lactation.     (2) 

The  removal  of  the  local  cause  by  operation  or  other  local  treatment. 
In  dealing  with  the  excessive  bleeding  which  is  associated  with 

some  disorder  of  menstruation  it  will  here  suffice  to  enumerate  the 

most  efficacious  uterine  hfemostatics  and  astringents  we  possess. 
1.  Heat. — By  the  vaginal  douche  and  water  at  115"  to  120.^ 
The  glass,  or  other  reservoir  filled  with  water  at  the   required 

temperature,  is  hung  on  a  nail  (or  placed  on  a  wardrobe)  about 

8  feet  high.     The  patient  (or  her  nurse) 

inserts  the  tube,  directing  it  backwards 

into  the  vagina,  and  by  turning  the  cock 

the  water  flows.     The  can  ought  to  be 

sufficiently  large  to  contain  2  quarts.     It 

is  preferable  to  have  the  assistance  of  an 

attendant  or  nurse.     Tincture  of  iodine, 

Kreuznach  liquor,  Woodhall   Spa  water, 

boric  acid,   bicarbonate    of    soda,    borax, 

Condy's  fluid,  liquid  extract  of  hydrastis, 

may  be  added  to  the  water. 

Misuse  of  the  Hot  Douche. — I  think  the  ad- 
monition of  W.  Goodell,  with  regard  to  the  hot 
douche,  contained  in  his  paper  on  'What  I 
have  learned  to  milearn,'  of  the  greatest  im- 
portance, and  it  is  one  in  which  I  fully  concur.* 

'  My  experience  teaches  me  that,  save  in 
some  cases  of  active  congestion  or  of  acute 
inflammation  of  the  pelvic  organs,  the  hot 
douche  is  of  questionable  utility,  and  that  its 
indiscriminate  emplojTiaent  has  done  far  more 
harm  than  good,  especially  when  continued  for 
any  length  of  time.  I  cannot  withhold  the  opinion  that  from  its  use  ovaritis, 
salpingitis,  and  peri-uterine  inflammation  have  actually  been  set  up  by  the 
over-heating  and  the  subsequent  chilling  of  the  pelvic  organs.  The  crucial 
test  of  surgical  research,  which  cannot  be  gainsaid,  has  shown  that  cellulitis 
is  almost  a  myth,  and  that  what  have  been  deemed  exudation  tumours  and 
inflammatory  deposits  in  the  areolar  tissue,  are  tubal  and  ovarian  lesions.' 

It  is  quite  true  that  the  use  of  the  hot  douche  degenerated  into  an  abuse, 
and  that  mischievous  effects  were  frequently  caused  by  a  remedy  which  was 
ordered  indiscriminately  for  everj'  form  of  pelvic  disease  that  manifested 
itself  by  a  hsemorrhagic  discharge. 


Fig.  157.  —  Usepdl  axd 
Portable  Can  Douche  in 
-WHICH  THE  Tube,  Pipe, 
AND    Thermometer     are 

PACKED   FOE   TRAVELLING. 

Others  can  be  had  with  the 
temperature  and  water- 
srauges  attached. 


*  Provincial  Medical  Journal,  vol.  x.,  p.  243. 


206  DISEASES   OF   WOMEN. 

2.  Cold. — Tagiaal  douche  ;  ice-bag  in  vagina  ;  irrigating  tube  in 
vagina ;  ice-bag  or  bladder  over  pubes.  Cold  is  always  to  be  used 
with  caution  where  there  is  great  debility  or  tendency  to  collapse. 
Leiter's  tubes  may  also  be  placed  over  the  uterus. 

3.  Tampon.  ^ — ^This  may  be  applied  in  the  form  of  a  sterilized 
sponge-tent  inserted  into  the  cervix — the  sponge  acts  both  as  a 
dilator  and  plug. 

Vaginal  Tampon  or  Plug^. 

In  cases  of  hsemorrhage  we  can  make  a  convenient  and  efficient  plug  thus  : 
A  roll  of  aseptic  wool  is  tied  in  the  centre  with  a  string,  and  spread  out  umbrella- 
shape  ;  several  small  pieces  of  wool  are  at  hand.  Moisten  the  surface  of  the 
wool  with  a  little  perchloride  or  the  subsulphate  of  iron  solution,  hazeline, 
hydi'astis,  glycerine  and  carbolic  acid,  glycerine  of  tannin,  or  glycerine 
and  permanganate  of  potash  solution.  A  Sims'  speculum  is  introduced. 
The  medicated  wool  with  the  string  attached  is  now  pressed  home  against 
the  OS — it  is  better  to  first  dry  the  part  thoroughlj' — and  following  it  the 
smaller  pieces  of  wool  are  pushed  in,  until  the  upper  part  of  the  vagina  is 
well  filled.  Always  remove  such  a  plug  after  twelve  hours.  If  we  want  more 
securely  to  fill  the  vagina,  we  may  use  strips  of  lint,  chinosol,  or  iodoform,  in 
the  form  of  a  '  kite's  tail.'  The  lint  may  be  moistened  with  tysoform  1  in 
1000,  carbolized  water,  perchloride  of  mercury  (1  in  10,000),  or  permanganate 
of  potash  solution. 

The  strings  attached  to  the  rolls  should  be  numerically  knotted  as  they  are 
inserted,  so  as  to  distinguish  them  in  removal. 

If  the  object  be  first  to  fill  the  space  of  Douglas,  the  better  plan  is  to  place 
the  woman  in  the  knee-elbow  position  and  fill  the  posterior  cul-de-sac  with 
several  small  tampons,  moistened  with  a  disinfectant. 

Two  rules  are  to  be  always  borne  in  mind  in  regard  to  plugging ; 
(a)  Never  look  upon  it  save  as  a  temporary  expedient  for  the  con- 
trol of  hsemorrhage  ;  (&)  never  permit  a  plug  to  remain  for  a  longer 
period  than  twenty-four  hours  at  the  outside  in  the  vaginal  cavity, 
and  always  disinfect  and  cleanse  the  Vagina  after  its  removal  and 
before  a  second  is  inserted. 

4.  Local  Astringents. — The  interior  of  the  uterus  may  be  wiped 
out  with  solutions  of  any  of  these  agents :  alum,  in  tampon  or 
injection ;  persalts  of  iron,  perchloride  of  iron,  either  as  the  liquor, 
or,  what  is  far  prefei'able,  the  solution  in  water  of  the  solid  salt, 
made  ■  any  strength  (grs.  xxx.  ad.  Ji.) ;  sulphate  of  iron  solution 
(5ss.  ad  5i-)  Sims);  ferro-alumen ;  gallic  acid;,  tannic  acid;  matico 
in  injection;  hamamelis,  adrenalin  or  renaglandin.  Vaginal  tam- 
pons of  glycerine,  and  liquid  extract  of  hydrastis  with  tincture  of 
matico,  are  very  efficacious. 


DISORDERS   OF  MENSTRUATION.  207 


5.  The  more  powerful  internal  therapeutic  remedies  are  ergot ; 
ergotine,  or  sclerotic  acid,  given  subcutaneously ;  ergotine,  with 
lupuline  and  quinine,  given  in  pill ;  tincture  of  perchloride  of  iron  : 
infusion  of  matico,  alone  or  in  combination  with  percliloride  of  iron, 
gallic  acid,  tincture  of  digitalis,  or  extract  of  hamamelis  ;  digitalis, 
in  combination  with  ergotine  ;  dried  sulphate  of  iron  and  quinine  ; 
gallic  acid  (gr.  xx.  doses),  with  infusion  of  matico  and  liquid  extract 
of  ergot,  or  the  ammoniated  solution  of  ergot  ;  ergole  ;  quinine,  with 
aromatic  sulphuric  acid  or  dilute  sulphuric  acid  ;  aletris  ;  viburnum  ; 
hydrastis. 

Hydrastine  Hydrochloride  (Hydrastia). 

The  clinical  indications  for  .the  emploii-ment  of  hydrastia  are  to  be  found 
especially  in  those  various  atonic  vascular  states  of  the  uterus,  occurring  at 
any  period  of  active  menstraal  life,  some  of  which  are  attended  by  excessive 
loss  of  blood,  either  of  the  menorrbagic  or  metrorrbagic  type.  It  is  also  of 
benefit  in  those  cases  of  congestive  dysmenon-boea  in  which  we  frequently 
find  the  severest  degree  of  menstrual  pain,  though  the  loss  of  blood  is  ex- 
cessive. My  experience  quite  confirms  that  of  Goth,*  that  it  is  especially  in 
haemorrhages  of  the  menopause,  provided  there  be  no  organic  changes  in  the 
uterine  tissues,  nor  intra-uterine  growths  present,  that  the  value  of  hydrastia 
is  best  seen.  I  speak  more  particularly  of  its  internal  use.  I  combine  with 
the  hydrastia  such  remedies  as  ergot,  or  ergotine,  sclerotic  acid,  cannabin, 
digitahs.  It  is  with  a  view  to  the  administration  of  these  diiigs  in  a  con- 
venient form  that  I  have  had  palatinoids  prepared.  H\-drastia  and  sclerotic 
acid  will  be  found  most  useful  in  vicarious  haemoptysis  or  epistaxis  (in  the 
latter  the  extract  may  be  used  with  glycerine  and  tincture  of  matico  most 
efficaciously  as  a  local  styptic,  or  on  a  tampon).  In  chronic  hyperplastic 
conditions,  in  the  earlier  stages  of  uterine  subinvolution,  in  the  '  secondary 
heemorrhages '  (McCIintock)  that  follow  abortion,  miscarriage,  or  labour, 
hydrastia  in  combination  with  other  astringents  will  be  found  valuable,  both 
administered  internally  and  applied  locally.  I  have  many  times  tried  both 
the  tincture,  extract,  and  alkaloid  in  various  forms  of  myomata.  The  results 
have  been  generally  disappointing.  There  have  been  some  modification  and 
partial  control  of  the  bleeding  occasionally,  but  no  permanent  or  marked 
relief.     The  alkaloid  hydrastinine  may  also  be  given. 

Stypticine  as  a  Uterine  Haemostatic. — I  frequently  use  stypticine  with 
hydrastia  in  the  treatment  of  uterine  haemorrhage.  It  is  one  of  the  oxidation 
products  of  narcotine.  The  dose  of  stypticine  is  0*05  gramme,  four  or  five 
times  in  the  day.  It  combines  a  sedative  with  its  styptic  action.  Goltschalk 
uses  it  as  an  adjuvant  to  the  curette.  It  must  be  remembered  that  it  is  an 
exciter  of  uterine  action,  and  hence  is  contra-indicated  in  threatened  abortion. 
It  is  a  powerful  vaso-constrictor.  The  haemorrhages  in  which  it  proves  of 
most  service  are  those  due  to  uterine  interstitial  fibroid,  and  in  menoiThagia 

*  Lancet.  February,  1887. 


208  DISEASES   OF    WOMEN. 

due  to  subinvolution.     I  have  had  it  combined  in  the  palatinoid  form  with 
ergotine,  hydrastia,  and  cannabin  tannate.     Thus — 

Hydrastia,  gr.  ^. 
Ergotin,  gr.  |. 
Cannabin  tannat,  gr.  \. 
Stypticin,  gr.  |-.     M. 
Also — 

Ext.  viburni,  grs.  ii. 

Ext.  hydrastis,  grs.  ii. 

Ext.  piscidise  erythinee,  gr.  i.     M. 

Vascular  Tonics  and  Haemostatics. — In  those  cases  of  atonic 
dyspepsia  and  general  debility,  so  commonly  met  with  in  women 
who  have  suffered  from  menorrhagia  from  any  cause,  especially 
those  who  have  lived  in  the  tropics,  if.  there  be  cardiac  weakness 
accompanying  the  dyspeptic  state  or  loss  of  appetite,  the  vascular 
tonics,  digitalis,  convallaria,  and  strophantJms,  in  combination  with  a 
uterine  hsemostatic,  are  indicated. 

In  my  first  contribution  to  periodical  literature,  I  urged  the  therapeutic 
value  of  digitalis  in  uterine  ha3morrhage  as  indicated  by  its  phj'siological 
action  on  the  arterioles.  In  such  cases  as  those  just  alluded  to,  in  which 
we  find  ventricular  incompetence,  this  drug  acts  well  with  hydrastis  when 
the  system  is  generally  enfeebled  by  repeated,  erratic,  and  excessive  loss  of 
blood.  The  value  of  strophanthus  in  dysmenorrhoea  has  been  pointed  out  by 
different  gynsecological  authorities,  and  its  use  in  cardiac  incompetence  is 
estabhshed.  The  uterine  hsemOrrhage  which  is  associated  with  aortic  disease 
is  most  troublesome  to  treat.  Here  strophanthus  is  specially  indicated.  It 
has  the  disadvantage,  as  compared  with  digitalis,  that  we  are  not  so  certain 
of  its  action  in  causing  contraction  of  the  arterioles,  and  its  effects  are  not  of 
so  permanent  a  nature.  But  in  those  cases  of  menorrhagia  and  metrorrhagia 
associated  with  cardiac,  functional,  or  organic  lesions,  occasionally  attended 
by  dysmenorrhoea,  the  administration  of  hydrastis  and  strophanthus  will  be 
found  of  great  service,  and  there  is  no  objection  to  the  addition  of  ergot. 
Strophanthus  in  such  cases  has  this  advantage  over  digitalis,  that  it  is  better 
tolerated  when  administered  for  any  length  of  time.  Hydrastis  is  a  valuable 
adjunct  to  the  uterine  tonics,  aletris  farinosa,  in  combination  with  '  celerina ' 
and  aletris  cordial,  and  I  have  frequently  given  these  drugs  in  palatinoids, 
with  great  benefit.  '  Celerina  '  (celery,  coca,  kola,  viburnum,  grs.  v. — 3I.)  is 
a  good  tonic  for  women  who  have  suffered  from  uterine  losses.  The  local 
use  of  hydrastis  in  uterine  afiections  is  as  important  as  its  internal  adminis- 
tration. The  fluid  extract  is  the  preparation  most  suitable  for  topical  use. 
In  cases  of  chronic  endometritis,  in  cervical  erosions,  and  after  scarification 
of  the  cervix  for  congestive  states  of  the  uterine  cervix,  the  fluid  extract 
combined  with  ichthyol  solution  (20  per  cent.),  carbolic  acid  or  iodine,  adding 
equal  parts  of  glycerine,  is  au  admirable  rQmedj'. 

As  a  cervical  dressing  it  will  be  found  of  service  applied  on  the  vaginal 


i>isoj:i>ers  of  MENsrnuArroN.  209 

tampon,  either  alone  or  with  one  of  the  above-named  additions.  The 
tampon,  first  soaked  in  glycerine  and  shaped,  has  the  fluid  extract  or  some  of 
the  compound  preparation  jioured  on  the  surface,  and  is  easily  applied  at 
night  by  the  patient  herself.  A  patient  should  he  taught  how  to  apply  a 
tampon  properly.  In  many  instances  it  might  as  well  be  left  on  the  toilet- 
table.  In  cases  where  the  use  of  the  hot  douche  (110*^  to  120°)  is  called  for, 
the  liquid  extract  of  hydrastis  (5ii.— 5iv.)  may  with  benefit  be  added  to  the 
water  contained  in  the  quart  can. 

The  general  management  of  the  patient  suffering  from  menor- 
rhagia  will  depend  on  the  constitutional  state  on  which  the 
haemorrhage  is  attendant.  General  or  ovarian  excitement  may  be 
controlled  by  bromides.  In  atonic  states,  strychnine,  in  combination 
with  quinine  and  ii-on,  is  indicated.  If  the  debility  induce  hysteria, 
valerian  (ammoniated  tincture  and  infusion)  is  an  admirable 
addition  to  the  bromide  preparations.  In  plethoric  conditions, 
at  the  time  of  the  menopause,  and  if  there  be  any  hepatic  con- 
gestion, saline  purgatives,  bitter  waters,  vegetable  cholagogues 
(podophyllin,  iridin,  euonymin),  altei-nated  occasionally  with  a 
mild  mercurial,  as  a  few  gi-ains  of  calomel  or  grey  powder,  should 
be  given.  If  loss  of  blood  should  have  induced  an  ansemic  or 
chlorotic  state,  iron  should  be  judiciously  administered  in  any  of 
the  forms  already  mentioned,  the  dialyzed  preparation  of  Squire, 
Fellows',  Easton's,  or  Dusart's  syrups,  Flitwick  iron  water,  haemo- 
globin, Blaud's  pills,  the  perchloride  tincture,  and  the  chloroxide, 
being  excellent  forms  to  administer  it  in.*  Haemoglobin  ti-oches  I 
have  had  made  in  the  form  of  syrup  to  avoid  the  unpleasant  taste 
of  the  drug. 

Operative  Interference. 

With  regard  to  the  operative  treatment  of  menorrhagia,  there  are 
such  minor  interferences  as  depletion,  dilatation,  section  of  the 
cervix,  and  the  operations  of  Sims  and  Dudley,  all  of  which  have 
their  special  indications,  and  are  relatively  valuable  according  to 
the  congenital  or  pathological  condition  present,  in  the  treatment 
both  of  dysmenorrhcea  and  menorrhagia.  Already  I  have  referred 
to  dilatation  and  exploration.  Dismissing  these,  there  are  a  few 
important  principles  to  bear  in  mind  when  dealing  with  dysmenor- 
rhcea, arising  from  pathological  states  of  the  uterus  and  adnexa. 
In  the  uterus  we  have  most  frequently  to  deal  with  displacements, 

*  For  reference  to  the  treatment  of  menorrhagia  by  electricity,  see  remarks  on 
Gynsecological  Electro-Therapeutics,  as  also  on  zestocausis  and  atmocausis. 

P 


210  DISEASES   OF   WOMEN. 

hyperplasiaj  chronic  endometritis,  interstitial  myomata,  and  intra- 
uterine fibroma.  With  regard  to  displacements,  while  I  do  not 
agree  with  those  who  say  that  the  days  of  all  pessaries  are  numbered, 
I  believe  that  the  time  is  rapidly  approaching  when  the  radical  cure, 
by  Alexander's  method,  or  by  ventro-suspension,  will  be  the  rule, 
and  the  wearing  of  an  internal  support  the  exception,  in  all  cases 
of  retroversion  in  which  reposition  is  difficult  and  recurrence  of 
the  malposition  inevitable  without  an  artificial  prop.  A  pessary 
in  anteversion  or  anteflexion  is  generally  mischievous.  Possibly 
Galabin's  is  the  least  so.  In  many  cases  there  will  be  found 
an  intramural  myoma  in  the  anterior  wall  of  the  uterus  which  de- 
mands enucleation.  Endometritis,  whether  hyperplastic,  catarrhal, 
hsemorrhagic,  or  gonorrhoeal,  requires  thorough  and  efficient  curet- 
tage, and  subsequent  following  up  of  the  operation  by  efficient 
treatment  until  complete  cure  has  been  efiected.  Small  intramural 
myomata,  which  are  often  multiple,  and  encroach  on  the  uterine 
canal,  may  be  enucleated  by  colpotomy.  Inti-a-uterine  fibromata, 
which  often  escape  detection,  causing  both  dysmenorrhoea  and 
menorrhagia,  are  as  a  rule  easily  removable  after  dilatation,  by 
ecraseur  or  polystome.  It  is  not  pleasant  to  find,  after  removal  of 
the  adnexa  for  incurable  dysmenorrhoea,  that  all  the  time  it  was 
due  to  an  intra-uterine  polypus. 

With  regard  to  the  adnexa,  whether  the  morbid  condition  be  in 
the  Fallopian  tube  or  ovary,  the  justification  for  interference  must 
entirely  depend  upon  the  clinical  symptoms  and  signs,  the  duration 
and  the  urgency  of  the  case.  Obvious  and  gross  changes  in  the 
female  genitalia,  as  elsewhere  in  the  body,  should  be  dealt  with  on 
broad  general  principles.  Useless  and  diseased  parts  should  be 
removed,  useful  and  healthy  portions  of  organs  preserved,  and,  with 
the  comparatively  slight  risks  involved  in  the  modern  operations 
both  of  colpotomy  and  laparotomy,  especially  the  former,  there  is 
no  surgical  excuse  for  procrastination  in  dealing  with  conditions 
that  may  sooner  or  later  destroy  not  only  an  organ  but  a  life. 


CHAPTER   IX. 
UTERINE    NEUROSES   AND    REFLEXES.* 

A.  FEW  observations  on  the  subject  of  uterine  reflexes  may  not  be 
out  of  place  now  that  we  have  considered  those  conditions  which 
are  mainly  associated  with  such  reflex  disturbances. 

The  connections  between  the  vagina,  uterus,  and  ovaries,  through 
their  nervous  supplies,  with  the  splanchnic  nerves,  and  with  the 
spinal  cord  in  the  sacral  and  lumbar  regions,  through  the  pelvic  and 
hypogastric  plexuses,  anatomically  explain  many  of  the  reflex  phe- 
nomena that  follow  upon  stimulation  or  irritation  of  the  ovarian 
and  utei'iue  nerves  consequent  upon  disease  in  the  ova  lies  or  uterus. 

The  reflex  connection  between  the  mammary  gland  and  the 
uterus,  and  between  the  latter  and  the  sciatic  nerve,  shows  that 
this  reflex  association  is  established  between  the  uterus  and  such 
a  distant  part  as  the  nipple,  and  with  peripheral  nerve-trunks,  as 
those  of  the  sciatic.  And  in  whatever  light  we  look  upon  ovula- 
tion, or  the  part  played  in  it  by  the  uterus  and  Fallopian  tubes, 
and  the  various  physiological  effects  brought  about  by  it  on  the 
entire  being  of  the  woman,  the  consequences  which  follow  a  devia- 
tion or  interruption  of  that  process  are  but  constantly  recurring 
demonstrations  of  the  physiological  effects  produced  under  its 
influence  in  almost  every  organ  in  her  body.  (This  influence  has 
been  fully  discussed  in  dealing  with  disorders  of  menstruation.) 

As  examples  of  this,  we  may  take  the  occurrence  of  varying 
shades  of  optic  neuritis  and  retinal  irritation  in  connection  with 
suppression  or  irregularity  of  the  catamenia ;  neuralgic  pains  in  the 
eyeball  associated  with  the  menstrual  epoch,  neuralgia  of  the  supra- 
and  infra-orbital  nerves,  slight  epileptiform  seizures  of  the  facial 
muscles,  toothache  and   dental    neuralgia,  laryngeal  migraine  and 

*  The  greater  part  of  this  chapter  was  written  many  years  since,  and  has 
undergone  but  little  alteration  in  successive  editions  of  the  work.  Since  then, 
the  subject  has  been  widely  discussed  by  British,  American,  and  foreign  gynje- 
cologists.     This  and  the  following  chapter  have  a  close  relation  to  each  other. 


212  DISEASES    OF   WOMEN. 

functional  aphonia,  or  paresis  of  the  intra-laryngeal  muscles,  milder 
forms  of  hypertrophic  rhinitis,  and  similarly,  tinnitus  aurium  and 
vertigo,  sympathetic  neuralgia  and  temporary  congestion  of  the 
mamma.  As  consequences  of  menstrual  irregularities,  we  find 
irritation  of  the  dorsal  and  lumbar  painful  spinal  zones,  herpetic 
eruptions  of  the  skin,  functional  irregularity  of  the  cardiac  rhythm, 
gastralgia  and  nausea,  slight  icteric  attacks,  atonic  or  irritable  states 
of  the  intestines,  irritation  of  the  bladder,  with  increased  frequency 
of  micturition,  pains  in  the  branches  of  the  lumbar  and  sacral  nerves ; 
varieties  of  headache,  and  severe  hemicrania.  All  such  symptoms  may 
be  accounted  for  by  reflex  vaso-dilating  or  vaso-contracting  effects 
produced  by  irritation  arising  in  the  uterus  or  ovaries,  as  the  result 
of  arrested  or  imperfectly  discharged  physiological  processes. 

The  ready  response  of  the  uterus  to  such  stimuli  as  an  anaemic 
blood  current,  or  one  in  which  there  is  an  excess  of  carbonic  acid, 
is  an  established  physiological  fact,  and  the  influence  of  such  reflex 
impressions  as  are  conveyed  by  a  cold  hand  on  the  abdomen,  or 
friction  of  the  mammary  gland,  has  been  obstetrically  availed  of 
from  early  times.  How  readily  its  catamenial  functions  are  disturbed 
by  such  causes  as  mental  or  physical  shock,  cold  and  heat,  we  are 
all  familiar  with.  So  it  must  happen  that  an  organ  so  susceptible 
to  any  direct  or  reflected  stimuli  will,  in  the  many  varying  states 
of  a  woman's  health,  or  the  incidental  occurrences  of  her  daily  life, 
respond  quickly  to  these  influences.  The  physiological  pain,  and 
the  much-debated  '  spasm '  of  dysmenorrhoea,  having  no  apparent 
cause  in  ovary  or  uterus  are  readily  accounted  for  by  an  ansemic  or 
toxsemic  blood-supply,  resulting  in  those  contractions  or  '  spasms ' 
that  attend  on  the  '  obstructive '  form  of  dysmenorrhoea.  It  un- 
doubtedly is  true,  as  insisted  on  by  Clifford  Allbutt,  that  the 
ill-health  of  the  woman  is  the  cause  of  the  ill-health  of  the  uterus 
in  many  cases.  It  is  equally  true  that  the  ill-health  of  the  uterus 
or  ovary  is  frequently  the  first  step  in  the  general  deteriorating 
process,  which,  as  it  originates,  so  it  maintains.  All  we  know  of 
the  physiology  of  uterine  action  compels  us  to  regard  the  uterus 
and  ovaries  as  the  strongest  links  in  the  chain  of  the  woman's  health 
of  mind  and  body.  Weaken  them  as  you  may  from  without  or 
within,  and  you  immediately,  but  fundamentally,  touch  all  the 
mainsprings  of  her  life. 

All  these  functional  disturbances  I  have  from  time  to  time  seen 
and  treated,  where  the  association  with  disorders  of  menstruation 
was  clearly  to  be  traced.     And  if  '  this  be  so  in  the  instance  of 


UTERINE  NEUROSES  AND  REFLEXES,  213 

aberrant  pliijslohxjical  functions,  how  much  more  likely  are  we  to 
have  such  consequences  following  gross  i)athjlogical  changes  in  the 
uterus  and  appendages.    And  this  we  find  to  be  practically  the  case. 

In  prolonged  disorders  of  the  uterus,  resulting  in  enlargement, 
hyperplastic  deposits,  or  a  process  of  fibrosis  following  on  arrested 
involution,  in  those  secondary  pathological  conditions  attending 
upon  lacerations  of  the  cervix,  in  deep  erosions,  in  unrelieved 
versions  and  Hexions,  in  tubal  enlargements  and  displacements,  and 
in  chronic  affections  of  the  ovary,  as  sequelae  of  pregnancy,  we  find 
not  only  these  reflexes  present,  but  more  aggravated  pathological 
consequences  and  more  serious  disturbances  of  function.  We  have 
this  association  exemplified  in  the  eye  in  thrombosis  or  embolism, 
in  retinal  infarctions  or  extravasations  with  their  secondary  conse- 
quences— atrophy  and  partial  or  complete  loss  of  vision ;  in  the  nose, 
in  epistaxis,  chronic  nasal  catarrhal  states  and  perversions  of  smell  ; 
in  the  ear,  in  labyrinthic  apoplexy,  with  all  the  symptoms  charac- 
teristic of  Meniere's  disease,  vertigo  and  deafness.  "We  see  the 
same  consequences  in  the  brain,  in  hallucinations  of  smell  and  taste, 
illusions  and  delusions,  from  slight  erraticisms  in  mental  action  to 
complete  perversion  of  the  mental  faculties,  as  in.  climacteric  mania  : 
in  the  nervous  system  generally,  in  such  evidences  of  instability  as 
aggravated  hysteria,  neuralgia,  hystero-epilepsy,  and  epilepsy.  In 
the  skin  these  manifestations  are  shown  in  such  nerve  disturbances 
as  prurigo  and  herpes,  or  in  the  appearance  of  acne  or  eczema.  The 
occurrence  of  "  nervous  '  alopecia,  and  the  aggravation  periodically 
of  any  chronic  disorder — as,  for  instance,  psoriasis  and  erythematous 
lupus — are  not  infrequent  results  of  menstrual  disorders.  I  have 
already  referred  to  menstrual  ulcer  and  pigmentary  changes.  In 
the  heart,  irritability  in  action  and  haemic  murmurs — conditions 
which  frequently  lead  to  a  permanent  hypertrophic  state,  or  are  felt 
through  attacks  of  syncope,  with  evidences  of  low  vascular  tension 
generally,  as  shown  by  an  habitually  compressible  pulse— are  common. 

We  meet  in  the  stomach  with  gastric  irritation,  with  possible 
congestive  changes  which  may  lead  up  to  gastric  ulcer.  There  are 
atonic  states  of  the  bowel  which  tend  to  constipation  on  the  one 
hand,  or  on  the  other  to  diarrhcea,  while  disordered  sexual  function 
and  perimetric  inflammation  frequently  lead  to  congested  conditions 
of  the  rectum,  complicate  haemorrhoids,  and  are  apt  to  produce  that 
irritability  of  the  sphincters  so  conducive  to  costiveness. 

The  important  bearing  of  uterine  affections  on  diseases  of  the 
rectum,  and  on  operative  interference  for  these,  in  preventing,  as 


2U  DISEASES   OF   WOMEN. 

long  as  they  are  unrelieved,  a  successful  issue  from  the  latter,  is 
well  known  to  any  one  who  has  had  experience  in  rectal  aifections. 
Hence,  in  a  great  number  of  cases,  the  necessity  imposed  of  delay- 
ing operation  until  the  uterine  affection  has  been  rectified. 

Apart  from  these  more  direct  consequences  of  pelvic  visceral 
disease,  there  are  those  indirect  results  that  follow  upon  interference 
generally  with  metabolic  changes  in  the  various  viscera,  consequent 
upon  abnormal  states  of  the  circulatory  fluid,  and  in  which  defective 
ovarian  or  uterine  functions  react  on  such  states  as  ansemia  and 
chloraemia,  thus  altering  the  normal  secreting  functions  of  the  liver 
and  kidneys,  and  seriously  interfering  with  the  metabolic  action  of 
the  spleen. 

Whether  such  conditions  are  primary  or  secondary  to  the  general 
state  of  health,  dependent  upon  these  interruptions,  matters  little  to 
us  as  practical  physicians.  So  long  as  we  recognize  the  physiological 
game  of  battledore  and  shuttlecock  that  they  play  in  deteriorating 
the  health  in  the  individual,  we  are  bound  to  recognize  and  treat  them. 

The  Neurotic  Temperament. — It  is  cruel  to  a  woman  to  style  her  '  neurotic,' 
'  hysterical,'  or  '  hypochondriacal,'  whUe  she  suffers  from  any  disease  of  her 
pelvic  viscera,  which  does  thus  accentuate  or  aggravate  the  ordinary  conse- 
quences that  attend  upon  any  abnormal  constitutional  condition.  It  is  some- 
thing more  than  injustice  to  her  if  we  deliberately  and  complacently  ignore 
the  influence  that  such  local  disease  exerts  in  exciting  morbid  impulses  in 
her  central  nervous  system.  This  danger  is  none  the  less  because  tempera- 
ment in  a  woman  plays  so  prominent  a  part  in  the  predisposition  to  disease 
and  the  susceptibility  to  pain.  We  must  be  careful,  however,  to  keep  the 
neurosis  associated  with  disease  quite  distinct  from  that  which  is  the  outcome 
of  temperament,  disposition,  and  habits. 

There  is  a  large  class  of  sufferers  from  affections  of  the  female  generative 
organs  which  is  commonly  spoken  of  as  '  nervous.'  The  neurotic  woman  is 
to  be  regarded  in  the  light  of  a  by-product  of  that  unstable  nei-vous  organiza- 
tion which  we  style  the  '  nervous  temperament,'  and  it  were  well  to  confine 
our  employment  of  this  term  '  neurotic '  to  such  abnormal  and  morbid 
exaggerations  of  this  temperament  as  are  not  uncommonly  foimd  associated 
with  pathological  conditions  of  the  woman's  pelvic  viscera.  Thus,  we  can 
frequently  trace  the  incipiency  of  the  neurosis  to  the  occurrence  of  some 
accident  or  injury,  which  may  have  had  a  dual  consequence  through  the 
infliction  of  shock,  or  the  displacement  or  affection  of  any  one  of  these 
organs.  Previous  to  such  accidental  determinations,  the  woman  may  have 
been  normal  in  the  control  of  her  will,  feeHngs,  and  emotions.  Her  energy 
and  impulses  have  directed  her  actions,  without  causing  that  sense  of  reac- 
tion and  fatigue  which  is  so  constantly  present  after  slight  exertion  when  her 
impulses  are  diverted  by  unhealthy  excitations,  and  her  energj'  is  dissipated 
by  morbid  introspections.  Such  a  nervous  temperament  is  frequently  satisfied 
with   little    sleep.     Under   the    influence    of  excitement,  fatigue   is  quickly 


UTERINE  NEUROSES  AND  REFLEXES.  215 

recovered  from,  and  a  latent  reserve  force  of  energy  appears  ever  ready  on 
demand  to  cany  its  possessor  over  insurmountable  obstacles.  All  this 
accumulated  governmental  control  of  will  and  nerve  energy  are  missing  in 
the  neurotic,  but  none  the  less  is  that  loss  felt  when  the  unequal  struggle 
occurs  between  the  sovereignty  of  an  enfeebled  indeterminate  will  and  the 
rebellious  and  more  masterful  emissaries,  the  woman's  'lower  passions  and 
lower  pains.'  While  in  health,  such  individuals  can  pass  through  great 
physical  and  mental  exertion  without  stimulants,  but  when  the  natural  call  on 
their  reserve  energy  finds  no  response,  they  apply  the  artificial  spur  of  alcohol 
or  some  other  excitant,  as  morphia,  to  the  flagging  nerve-cells.  Such  women 
are  quite  cognizant  of  the  abeyance  of  the  power  to  exercise  free  will.  The 
desire  to  suppress  the  expression  of  pain  is  present,  but  the  usual  control  is 
lost.  Also,  there  is  general  hyperesthesia  of  the  peripheral  nerves,  which 
tind  in  the  frequently  LQ-nourished  cells  a  susceptibility  to  slight  impulses  and 
morbid  sensitiveness,  with  an  exaggerated  perception  of  comparatively  trifling 
stimulation.  Here  we  are  dealing  with  an  acquired  neurosis,  for  which 
possibly  we  may  find  no  clue  through  ata^^stic  transmission.  On  the  other 
hand,  we  can  frequently  see  in  early  childhood  the  traits  of  temperament 
which  clearly  foretell  the  future  neurotic  woman.  Capriciousness,  irritability, 
selfishness,  restlessness,  and  excitability,  are  among  the  mental  characteristics 
which  stamp  the  moral  prototype  in  the  child  of  the  adult  neurasthenic  and 
hysterical  woman,  though  it  is  after  puberty  that  we  frequently  find  such 
distinctive  features  of  character  develop  themselves.  When  a  woman  of  this 
type  marries,  in  the  demands  on  her  nervous  system,  if  she  be  not  sterile, 
which  the  claims  of  children  and  domestic  duties  involve  her  in,  she  generally 
escapes  those  neurotic  and  hj'sterical  manifestations  that  are  foimd  in  the 
unmari'ied  and  sterile.  In  the  single  woman  of  the  '  neurotic  '  type,  we  are 
most  likely  to  meet  "with  those  erotic  thoughts,  desires,  and  practices  that 
still  further  enervate  her  nervous  system  and  enfeeble  her  central  control. 

Turn  we  now  for  a  moment  to  the  Jympliatic  antithesis  of  this  unfortunate 
victim  to  morbid  nerves  and  sexual  impulses. 

The  Lympliatic  Temperament. — There  is  a  type  of  woman,  familiar  to  us  all. 
indolent,  lethargic,  fanciful  of  ailments,  with  a  superficiality  bordering  on 
childishness  in  conversation,  dull  of  comprehension,  readily  open  to  flattery, 
even  to  her  own  self  a  bore,  and  frequently  one  to  her  husband  and  children 
if  she  be  married.  She  is  often  found  fringed  with  layers  of  pectoral  and 
abdominal  fat,  the  easy  prey  to  quack  systems  of  dieting,  and  to  the  '  man  of 
the  world'  physician.  Her  defective  metabolism,  added  to  a  sexual  voluptuous- 
ness, makes  her  the  registered  dual  property  of  the  '  pure  specialist '  for  gout 
on  the  one  hand,  and  the  cotton-wool  gynsecologist  on  the  other.  She  is  one 
of  the  principal  sources  of  revenue  to  the  Franc  Tireurs  of  the  outposts  of 
medicine — the  ubiquitous  masseurs  or  masseuses — as  the  previously  described 
sufferer  is  to  the  fashionable  '  Weir  Mitchell  Home.'  With  her,  every  twinge 
is  '  agonizing,'  to  walk  is  impossible,  and  once  let  her  evolve  '  uterus  and  ovary 
on  the  brain,'  and,  whether  these  organs  be  diseased  or  not,  they  are  made 
responsible  for  every  ill  her  peccant  flesh  is  heir  to.  She  is  not  of  the  classical 
neurotic  type  previously  described,  though  her  visceral  neuroses  may  in  time 
come   to   be  legion.     She  may  suffer  from  congestive  dysmenorrhcea   and 


216 


DISEASES   OF   WOMEN. 


ovaralgia,  her  uterus  may  be  as  flabby  as  her  brain,  and  her  ovary  be  as 

fertile  in  aches  as  her  imagination  is  in  fanciful  illusions.  Her  voluptuosity 
is  not  Hmited  to  her  appetites  of  palate,  and  it  is  not  infrequently  manifested 
in  various  sexual  abuses.  She  fancies  that  she  sleeps  for  many  hours  less 
than  she  actually  does,  and  hence  is  often  seeking  for  some  new  hypnotic. 
While  v?e  find  in  the  unmarried  more  frequent  examples  of  the  first  type  of 
temperament,  married  women  furnish  a  larger  proportion  of  the  latter. 

In  two  hundred  and  seventy  cases  of  disease  and  abnormal  conditions  of 
the  sexual  organs  in  women,  selecting  those  cases  in  which  no  special  func- 
tional or  organic  troubles  in  any  other  organ  were  more  particularly  com- 
plained of,  from  a  total  of  some  five  hundred,  I  give  a  brief  analysis  of  the 
associated  mischiefs  which,  in  the  vast  majority  of  the  cases  quoted,  were 
secondary  to  the  afi'ections  of  the  sexual  organs.  Cases  are  not  included  in 
which  there  were  grosser  changes,  such  as  large  fibroids  and  ovarian  cystoma. 
The  comparative  ages  of  these  patients  are  roughly  shown  in  this  table  : 


Cases 

Under  20 

7 

20—30  .... 

.      90 

30—40   .... 

.     102 

40—50   .... 

.       63 

50-53   .... 

8 

270 


195  married  ;  75  single. 


The  principal  abnormal  state  present  in  each  case  was : — 

Eetroversion,  with  or  without  flexion 
Marked  anteversion,  with  flexion    .... 
Ovarian  enlargement,  with  or  without  tubal  affection 
Eetroversion,  with  ovarian  and  tubal  complications 

Subinvolution  of  uterus 

Erosion  of  cervix,  with  or  without  endocervicitis     . 

Hypertrophic  condition  of  uterus     .... 

Hypertrophic  condition  of  uterus,  with  ovarian  complications 

Endometritis,  with  or  without  ovarian-  complications 

Extensive  laceration  of  cervix 

Stenosis,  with  congenital  malformation 

Small  fibroid  tumours     . 

Intra-uterine  polypus 

Sarcoma  of  uterus 

Symptoms  incidental  to  menopause 

A  direct  sequel  to  pregnancy  . 

Suppression  of  catamenia 

Vaginismus    ..... 

Absent  perineum    .... 

Total 


Cases. 

55 
11 
23 
11 
33 
22 

6 

9 
14 

6 
15 
11 

2 

1 
29 

1 
18 

1 

2 

270 


UTERINE  NEUROSES  AND  REFLEXES.  217 


Of  the  entire  number  quoted,  fourteen  were  not  submitted  to  local  exami- 
nation, and  are  included  under  the  head  of '  Suppression  of  catainenia.' 

AVe  turn  now  to  the  symptoujs  other  than  uterine  or  ovarian  complained 
of  in  the  two  hundred  and  seventy  cases. 

No  case  of  malignant  disease  is  included  save  one  of  sarcoma. 

The  following  are  the  principal  signs  and  symptoms  complained  of  by  the 
two  hundred  and  seventy  patients  : — 


Anaemia          ..........  19 

Skin   affections    (as   eczema,    erythema,    acne,   erythematous 

lupus,  alopecia,  psoriasis,  prurigo) 13 

Head  symptoms   (as   aggravated  headache,   'fulness  in  the 

head,'  loss  of  memory) 53 

Facial  neuralgia     .         .         .         .         .         .         .         .         .15 

Neurasthenia.         .........  45 

Migraine         ..........  16 

Mammary  sympathies  (as  neuralgic  pains,  glandular  changes)  6 

Spinal  pain  and  irritation        .......  10 

Intercostal  neuralgia       ........  25 

Numbness  of  upper  extremities 4 

Numbness  of  lower  extremities 4 

Pain  in  upper  extremities       . 2 

Pain  in  lower  extremities       .......  9 

Stiffness  in  ankles  with  each  period 1 

Catalepsy       ........••  2 

Hysteria .  13 

Insomnia        ..........  15 

Epilepsy 3 

Tendency  to  melancholia,  depression 9 

Dementia       .         , 4 

Agorophobia 1 

Ophthalmic  symptoms  dependent  upon  abnormal  retinal  states 
(as  optic  neuritis,  pathological  changes  in  papilla,  hyperaemia 

of  retina,  asthenopia)           .......  15 

Nasal  symptoms  due  to  turbinate  congestion  or  hypertrophy  .  5 
Laryngeal  symptoms,  such  as  varying  degrees  of  aphonia  due 

to  paresis  of  laryngeal  muscles,  hypersemia  of  vocal  cords   .  12 

QEsophageal  spasm 1 

Thyroid  enlargement     . .1 

Tinnitus  aurium     . 7 

Sickness  and  nausea 5 

Gastralgia       ......••••  15 

Dyspepsia      .         .         •         .         •         •         •         •         •         .11 

Cardiac  symptoms   (as  irregularity  of  rhythm,  intermission, 

dyspnoea,  haemic  bruit)        .......  33 

Attacks  simulating  angina  pectoris          .         .         .         .         •  1 

Abdominal  symptoms  (as  erratic  pains,  flatus,  hepatic  engorge- 
ment, dysenteric  symptoms,  diarrhcea)         ....  17 


218  DISEASES   OF   WOMEN. 

Cases. 

Aggravated  constipation 11 

Pain  and  irritability  of  rectum 4 

Vesical  symptoms  (as  irritation,  difficulty  of  retention  or  pain 

with  micturition,  vesical  pain) 30 

Difficulty  of  locomotion 24 

Impairment  of  general  health 54 

Painful  sitting 1 

Epistaxis        ..........  2 

Defective  circulation — lividity  of  upper  and  lower  extremities  2 

Under  the  heading  of  '  aggravated  headache  '  should  be  frequently  included 
symptoms  such  as  those  described  as  '  fulness  in  head,'  '  pressure  on  head,' 
'  sense  of  tightness,'  and  'flushings.'  *  Under  that  of  neurasthenia  are  included 
those  well-known  unstable  states  of  the  nervous  system  generally,  which 
embrace  various  morbid  apprehensions,  fits  of  depression,  uncertainties  of 
sight  and  touch,  disturbance  of  sleep,  irritability  or  capriciousness  of  temper. 

Under  '  difficulty  of  locomotion '  ai"e  only  reckoned  those  cases  in  which 
there  was  a  decided  inability  to  walk.  'Impairment  of  general  health' 
includes  such  general  conditions  as  'lassitude,'  feeble  circulation,'  'weak 
cardiac  action,'  '  alteration  in  the  specific  gravity  of  urine,'  '  tendency  to 
syncope,'  '  loss  of  appetite,'  and  proofs  in  the  complexion  and  facial  expres- 
sion of  great  enfeeblement  of  the  system.  The  throat  and  skin  have  likewise 
their  reflex  relationships  with  the  organs  of  generation  in  women.  The 
slight  elevation  of  temperature  in  the  skin  during  the  catamenial  period  is  a 
physiological  fact  worth  remembering. 

Such  evidence  has  convinced  me  that  many  distant  lesions  and 
remote  symptoms  are  due  to,  and  have  their  exciting  cause  in, 
uterine  irritation. 

The  alternating  and  dominating  influence  exerted  by  body  and 
mind  over  each  other  in  maintaining  or  disturbing  that  healthful 
harmony  essential  to  the  preservation  of  a  normal  balance  of  power 
betwixt  the  two,  is,  in  my  opinion,  nowhere  better  exhibited  in  the 
organism  than  by  the  effects  produced  in  the  nervous  system  of  a 
woman  by  the  ordinary  physiological' variations  in  the  health  of  her 
sexual  organs.  How  far  that  harmony  is  influenced  by  functional 
or  pathological  deviations  from  a  healthy  state  of  these  organs,  is 
shown  clearly  by  the  list  of  nervous  affections  just  cited. 

While  thus  insisting  on  the  part  played  by  the  sexual  organs  of 
women  in  the  causation  of  reflex  neuroses,  visceral,  and  other,  the 
weighty  words  of  Goodell  should  be  kept  in  mind  : — 

Mimicry  of  Uterine  Affections.* — 'I  have  learned,'- he  says,  'to  unlearn  the 
idea  that  uterine  symptoms  are  always  present  in  cases  of  uterine  disease, 
or  that,  when  present,  they  necessarily  come  from  the  uterine  disease.     The 

*  See  remarks  on  Eye  Strain,  Chapter  III. 


UTERINE  NEUROSES  AND  REFLEXES.  219 

nerves  are  mighty  mimics,  the  greatest  of  mimics,  and  cheat  us  by  their 
realistic  personations  of  organic  disease,  and  especially  of  uterine  disease. 
Hence  it  is  that  seemingly  urgent  uterine  symptoms  may  be  merely  nerve- 
counterfeits  of  uterine  disease.  I  have,  therefore,  long  since  given  up  the 
belief,  which  with  many  amounts  to  a  creed,  that  the  womb  is  at  the  bottom 
of  nearly  every  female  ailment. 

'  Nerve-strain,  or  nerve-exhaustion,  comes  largely  from  the  frets,  the 
griefs,  the  worries,  the  carks  and  cares  of  life.  Yet  although  the  imagination 
undoubtedly  affects  it,  it  is  not  a  mere  whim  or  an  imaginary  disease,  as  all 
healthj'  women  and  most  physicians  think  ;  but  it  is  the  veriest  of  realities. 
When  some  flippant  talker  or  some  slipshod  thinker  scoffs  at  nervousness 
as  a  sham  disorder,  I  say  to  him  :  "  Can  the  bribe  of  a  principality  keep  you 
from  blushing  when  you  are  ashamed,  or  from  blanching  when  you  are  afraid  ?  " 
Under  the  fitting  sense  of  shame  or  fear,  these  vaso-motor  disturbances  are 
momentarily  beyond  your  control ;  and  so  they  are  in  the  nervous  woman, 
whose  vital  organs  are,  as  it  were — not  transiently,  but — perpetually  blushing 
and  blanching  under  deficient  brain-conti'ol  over  the  lower  nerve-centres.' 

'  Strangely  enough,  the  most  common  symptoms  of  nerve-disorder  in  women 
are  the  very  ones  which  lay  tradition  and  empiricism  attribute  to  womb- 
disease.  They  are,  in  the  order  of  their  frequency,  great  weariness,  and 
more  or  less  of  nervousness  and  wakefulness  ;  inability  to  walk  any  distance, 
and  a  bearing-down  feeling  ;  headache,  napeache,  and  backache ;  scant,  pain- 
ful, delayed,  or  suppressed  menstruation ;  cold  feet,  and  an  irritable  bladder ; 
general  spinal  and  pelvic  soreness,  and  pain  in  one  ovary  (usually  the  left),  or 
in  both  ovaries.  The  sense  of  exhaustion  is  a  remarkable  one ;  the  woman  is 
always  tired;  she  passes  the  day  tired,  she  goes  to  bed  tired,  and  she  wakes 
up  tired — often,  indeed,  more  tired  than  when  she  fell  asleep. 

'  Now,  let  a  nervous  woman  with  some  of  the  foregoing  group  of  symptoms 
recount  them  to  a  female  friend,  and  she  will  be  told  that  she  has  a  womb- 
disease.  Let  her  consult  a  physician,  and  ten  to  one  he  will  think  the  same 
thing,  and  diligently  hunt  for  some  uterine  lesion.  If  one  be  found,  no  matter 
how  trifling,  he  will  attach  to  it  undue  importance,  and  treat  it  heroically  as 
the  peccant  organ.  If  no  visible  disease  of  the  sexual  organs  be  discoverable, 
he  will  lay  the  blame  on  the  invisible  endometrium  or  on  the  imseeable 
ovaries,  and  continue  the  local  treatment.  In  any  event,  whatever  the 
inlook  or  the  outlook,  a  local  treatment  is  bound  to  be  the  issue.' 


CHAPTER  X. 

AFFECTIONS  OF  THE  FEMALE  GENITALIA  AND 
THEIR  SPECIAL  BEARING  ON  THE  OPERA- 
TIVE   TREATMENT    OF    THE    INSANE.* 

Physiological  and  Psychopathic  Considerations. 

It  is  an  easy  task  to  show  that  intimately  associated  with  certain 
problems  in  psychiatrics  are  others  which  require  for  their  elucida- 
tion the  observation  and  research  of  the  gynaecologist.  Por  this 
purpose  we  have  to  go  no  further  than  the  psycho-physical,  psycho- 
physiological, and  psycho-pathological  phenomena  attendant  upon 
the  act  of  ovulation  and  its  expression  in  the  menstrual  discharge, 
as  they  are  made  manifest,  not  only  during  abnormal,  but  also  in 
normal,  menstruation.  Also,  interferences  in  any  part  of  the  cycle 
of  metabolic  phenomena,  which,  combined,  constitute  a  complete 
menstrual  period,  have  so  often  correlated  with  such  disturbances 
varying  shades  of  disordered  mentalization,  from  the  slight  and 
almost  imperceptible  deviation  from  health,  to  those  more  pro- 
nounced interruptions  of  the  mental  equilibrium  which  bring  us  to 
the  borderland  of  insanity,  if  not  to  the  ideas,  impulses,  and  actions 
of  the  completely  disordered  mind.  Such  psychical  and  psychopathic 
associations  or  sequences  have  their  anatomico-physiological  ex- 
planation, through  the  various  lympiiatic,  vascular,  and  nervous 
supplies  and  distributions  of  the  sexual  organs  involved  in  the  process 
of  ovulation.  We  have  then  also  present  that  condition  of  nervous 
exaltation  in  which  reflex  action  and  morbid  reflexes  are  easily 
excited,  and  when  abnormal  manifestations,  both  motor  and  sensory, 
are  present.  The  physiological  and  psychical  influences  operating 
during  the  developing  years  of  adolescence,  and  at  the  climacteric 
period  of  life,  tend  in  the  first  case  to  such  disorders  as  epilepsy, 

*  This  chapter  is  abridged  from  the  Author's '  Practical  Points  in  Gynaecology,' 
and  having  been  written  more  recently  is  substituted  for  that  on  the  same  subject 
in  the  last  edition. 


THE   GEX ITALIA    AXD    IXSAX/Tr.  -Ill 


chorea,  suicidal  promptings,  persecutory  delusions,  distorted  sexual 
impulses,  and  more  particularly  in  the  latter  to  the  various  delusional 
states  attendant  upon  melancliolia  or  dementia  which  are  then  met 
with.  Common  among  these  are  those  morbid  ideas  of  a  sexual 
nature  connected  either  with  the  woman  herself,  or  others  having 
relation  to  her  married  state.  Such  terminological  divisions  in  the 
classiiication  of  insanity  as  '  masturbational,'  'ovarian,'  'climacteric,' 
'  old  maids,'  show  the  recognition  by  psychologists  of  such  influences. 
We  are  not  now  considering  such  morbid  mental  conditions  as  are 
consequences  of  pregnancy,  labour,  and  lactation.  These  phases  of 
adolescence  and  the  menopause  are  weaker  links  in  the  chain  of  the 
woman's  life,  which,  when  its  strength  is  tested  by  any  exceptional 
strain,  either  by  the  influence  of  the  environment  of  her  social 
position  and  surrounding  circumstances,  her  calling,  or  accidental 
occurrences,  yield  through  some  pre-existing  flaw,  and  the  sudden 
snap  ensues. 

At  these  times  'predisposing  factors,'  transmitted  by  heredity, 
combine  to  generate,  evolve,  and  crystallize  certain  psychopathic 
tendencies  and  impulses,  which  are  released  by  a  weakened  inhibitory 
will-power  and  ineffective  nerve-control.  Such  morbidly  impression- 
able conditions  are  hyper-sensitiveness  to  pain,  neuroses  of  the 
viscera,  of  the  respiratory,  circulatory,  or  digestive  systems,  and 
temporary  exaggeration  of  some  or  all  of  the  temperamental  traits 
which  distinguish  the  individuality  of  the  woman,  such  as  greater 
excitability,  unaccountable  fits  of  depression,  irascibility,  or  lethargy. 
We  employ  to  such  mental  types  and  nervous  characteristics  the 
terms  '  neurasthenic '  or  '  neurotic'  A  stage  further,  and  we  regard 
the  state  as  one  of  '  hysteria,'  with  which  possibly  we  have  allied 
that  of  hypochondriasis. 

With  regard  to  this  class  of  case,  in  which  there  is  not  any  pro- 
nounced mental  affection,  it  is  to  be  regretted  that  the  subjects  of 
such  nervous  disorders  have  their  mental  symptoms  generally  re- 
garded either  with  indifference  or  suspicion  by  advisers  and  friends 
alike.  Frequently  it  happens  that  they  are  practically  ignored, 
while  excess  of  attention  is  paid  to  the  visceral  affection,  pelvic  or 
other ;  or,  on  the  other  hand,  undue  importance  is  given  to  them, 
at  the  cost  of  disregarding  the  source  of  some  reflex  distm'bance 
which  may  be  the  principal  factor  in  causing  the  mental  insta- 
bility. 

As  Dr.  Urquhart  well  puts  it,  '  The  nervous  system  in  slighter  or  incipient 
cases  may  be  but  slightly  affected,  and  it  is  in  regard  to  these  less  marked 


222  DISEASES   OF   WOMEN. 

cases  that  special  study  is  so  much  required.  The  neglect  of  careful  observa- 
tion and  investigation,  in  the  light  of  recently  acquired  knowledge,  is  much 
to  be  deplored.  Asylum  physicians  seldom  see  the  begirming  of  mental 
disorder,  and  although  they  have  asked  for  information,  little  has  been 
forthcoming."  * 

He  further  says : 

'  I  am  one  of  those  who  see  no  real  fundamental  difference  between  mental 
disorder  of  the  technical  legal  kind  and  neuroses.  They  are  all  part  and 
parcel  of  the  same  inherent  defect.  We  cannot  naiTow  our  view  to  the  mere 
facts  of  disordered  mentalization ;  we  must  consider  the  influence  and 
relations  of  environment,  of  such  conditions  as  gout  and  rheumatism.' 

Dr.  Barracloughjt  late  of  the  Wilts  County  Asylum,  says  :  '  On  this  point 
I  must  speak  with  no  uncertain  sound.  In  my  opinion  the  neurotic  tempera- 
ment is  almost  as  much  a  predisposing  factor  as  is  insanity  itself.  Very 
frequently,  when  the  most  careful  search  cannot  detect  any  trace  of  family 
insanity,  an  interview  with  the  parents  is  sufficient  to  show  whence  the 
inherited  tendency  lies.  I  have  one  case  under  my  care  at  the  present 
moment  who  is  now  hopelessly  insane,  and  who  has  no  family  history  of 
insanity,  but  whose  parents  are  both  extremely  neurotic,  especially  the 
father,  and  one  of  whose  sisters  is  very  hysterical.'  He  quotes  another  case 
of  a  similar  nature,  and  goes  on  to  say  that  it  would  almost  appear  that 
psychopathic  predisposition  and  neurotic  temperament  are  cumulative  in 
tbeir  effects,  as  they  are  transmitted  from  parents  to  offspring,  and  must 
ultimately  terminate  in  insanity  in  the  most  highly  unstable  of  their 
descendants. 

Dr.  Eooke  Ley,J  of  the  Prestwich  Asylum,  lays  particular  stress  on  neuro- 
pathic heredity  as  the  main  point  to  be  considered  in  relation  to  mental 
disorders  occurring  at  adolescence,  and  considers  that  such  '  psychopathic 
predisposition  and  neurotic  inheritance  play  a  very  large  part  in  the  causation 
of  disordered  mentalization  .  .  .  and  that  the  local  affection  lights  up  as  it 
were  the  inflammable  material  ready  for  a  suitable  torch.'  And  if  we  take 
the  opinions  of  gynaecologists  generally,  we  have  the  same  view  strongly 
expressed  that  psychopathic  predisposition  is  nearly  always  present  when  we 
find  a  disorder  of  menstruation  or  an  operation  on  the  sexual  organs  causing 
alienation. 

Etiological  Differentiation. — Herein  we  meet  with  the  first 
difficulty  in  the  differentiation,  etiologically,  of  cases  of  mental  dis- 
turbance in  women  in  whom  a  sexual  disorder  is  suspected  or 
discovered.  By  critical  inquiry  into  the  family  history  and  personal 
temperament  or  peculiarities  of  a  patient,  we  may  satisfy  ourselves 
as  to  the  part  played  by  heredity,  not  forgetting  the  subtle  trans- 
missions to  the  individual  through  atavism,  and  thus  separate  the 

*  Communication  to  the  author. 

t  See  '  Practical  Points  in  Gynaecology,'  3rd  edition,  1902. 

X  Communication  to  the  author.     • 


THE  GENITALIA   AND   INSANITY.  223 

class  of  case  in  which  psycopathic  factors  have  prepared  the  soil  for 
the  germs  of  a  mental  affection  from  that  in  which  a  sexual  disorfler 
appears  to  act  primarily  and  directly  as  the  exciting  cause  of  the 
distux'bance. 

As  Claye  Shaw  well  insists,  we  begin  by  recognizing  the  dual  nature  of 
sexual  delusions — those  that  are  purely  mental  without  relation  to  the  sexual 
organs,  and  those  which  have  their  origin  in  the  latter  :  uterine  or  ovarian 
disease  is  commonly  present  without  insanity ;  or  a  sexual  form  of  insanity 
exists  without  disease  of  the  genitalia ;  or  insanity  exists  without  sexual 
delusions,  while  various  disorders  of  mentalization  appear  to  have  a  distinct 
relation  to  diseases  of  the  genitalia.  Obviously,  it  must  be  most  difficult, 
often  impossible,  to  differentiate  between  these  classes,  and  no  satisfactory 
conclusion  can  be  arrived  at  in  a  proportion  of  them,  wthout  a  careful 
psycho-gyuEecological  examination.  How  far  such  dual  examination  may  be 
advisable  will  depend  upon  such  considerations  as  the  age  of  the  patient,  the 
history  of  previous  sexual  disorder,  and  the  signs,  positive  and  negative,  as 
well  as  the  symptoms  which  may  be  present,  of  a  pathological  or  physio- 
logical nature,  indicative  of  a  sexual  affection.  In  the  young  adolescent  our 
great  difficulty  is  to  determine  whether  the  aberration  in  ovulation  is  not  the 
consequence  rather  than  the  cause  of  the  mental  condition  ;  as  Yellowlees  * 
says,  '  There  can  be  no  doubt  that  the  amenorrhoea  is  as  often  the  result  of 
defective  nerve  conditions  as  their  cause.'  'Derangements  of  menstruation,' 
remarks  Rooke  Ley,  '  do  act  as  potent  causes  of  insanity,  but  to  a  much  less 
extent  than  some  observers  maintain;  but  they — especially  amenorrhcea — 
are  more  often  the  result  rather  than  the  cause.' 

Instances  of  disturbance  of  mentalization  during  adolescence  are 
amongst  the  most  frequent  that  the  gynaecologist  meets  with,  though 
not  uncommonly  the  mental  specialist  is  the  first,  if  not  the  only 
one,  under  whose  observation  they  come. 

I  have  had  examples  of  many  such  cases  under  my  care,  and 
many  more  in  which  associated  physical  and  mental  weakness  or 
distinct  psychopathic  manifestations  of  a  pronounced  nature  have 
preceded  the  menstrual  irregularity  and  interfered  with  the  process 
of  ovulation.  In  the  great  majority  of  young  patients,  however,  we 
meet  rather  with  varying  aspects  of  neurasthenia,  phases  of  epilepsy, 
chorea,  hysteria,  and  visceral  neuroses,  neuralgias,  and  disorders  of 
the  special  sense  organs,  and  peripheral  and  central  reflex  irritations. 

Masturbation. — So  far  as  masturbation  is  concerned,  we  are  con- 
fronted with  somewhat  the  same  difficulty.  Is  it  the  cause  or  the 
consequence  of  the  nervous  and  mental  perturbation?  There  can 
be  no  doubt  that  heredity  here  again  plays  an  important  part  in 
the  tendency  to   and   persistence  of  the  desire.     Some  victims  are 

*  Communication  to  the  author. 


224  DISEASES   OF    WOMEN. 

such  by  congenital  transmission,  and  in  these  adolescents  it  is 
doubtful  if  they  are  ever  completely  cured  and  saved  from  nympho- 
mania, save  by  the  legitimate  call  on  the  natural  physiological 
response  that  alone  healthily  satisfies  the  sexual  demand. 

I  have  known  several  instances  of  women  who  had  no  immoral  tendencies 
whatever,  whose  minds,  in  regard  to  all  their  worldly  relations,  were  stable, 
active,  and  intelligent,  who  commenced,  unwitting  as  to  its  evil  or  pernicious 
nature,  the  practice  of  self-abuse,  and  who  persisted  secret!}''  in  the  habit 
during  adolescence  without  its  producing  any  apparent  ill  effect. 

In  relation  to  the  congenital  nature  of  morbid  sexual  instinct,  it  has  to  be 
remembered  that  in  some  females  this  is  developed  at  a  very  early  age, — in 
one  case  under  my  obsei'vation,  in  a  child  under  five  years,  so  strongly,  that 
it  was  impossible  to  leave  her  for  any  time  ia  the  company  of  male  children. 
I  have  seen  mastm-bation  associated  with  every  type  of  neurosis,  and  I 
believe  it  to  be  a  potent  factor  in  the  causation,  evolution,  and  development 
of  psycopathic  propensities,  even  to  the  extent  of  unnatural  indulgences. 
Yet  1  have  not  known  any  case  in  which  insanity  can  be  traced  to  this  source 
alone.  The  presence  of  some  such  vice  amongst  the  insane  is  frequent,  but 
the  vicious  propensity  occurs  as  only  one  of  many  morbid  evidences  of  the 
neurotic  temperament  and  disposition  from  which,  at  the  period  of  developing 
sexual  excitations,  it  springs.  Should  such  disturbances  as  melancholia  or 
dementia  arise  in  these  women,  the  vice,  by  its  general  influence,  both 
physical  and  psychical,  may  help  to  encourage  or  perpetuate  some  delusional 
or  melancholic  condition,  and  render  its  cure,  if  the  habit  be  persisted  in,  all 
the  more  difficult. 

Clitoridectomy. — Taking  these  facts  into  consideration,  it  is  apparent  why 
clitoridectomy  has  frequently  failed  to  effect  a  cure  of  affections  which  are 
supposed  to  be  the  consequences  of  masturbation.  The  morbid  reflexes  in 
the  great  majority  of  these  cases  have  a  central  and  not  peripheral  origin, 
and  in  most  of  those  in  which  morbid  peripheral  excitations  are  present, 
they  are  secondary  consequences  of  the  general  state  of  neurasthenia,  hysteria, 
or  hystero-neurosis,  present.  The  operation  can  at  best,  under  such  circum- 
stances, be  experimental,  and  the  after-effects  on  the  woman's  mind  may 
make  her  last  state  worst  than  the  first. 

Pubescent  Insanity. — The  vital  lesson  learnt,  both  from  the 
etiology  and  development  of  pubescent  insanity,  so  far  as  the  young 
female  is  concerned,  is  that  the  children  of  neurotic  and  mentally 
unstable  parents,  of  too  early  marriages,  of  blood  relationships,  and 
of  alcoholics,  require  special  care  and  judgment  in  their  companion- 
ships, amusements,  and  occupations,  and  in  the  general  watchful- 
ness of  their  tendencies,  habits,  and  mannerisms.  And  inasmuch 
as  in  these  we  are  far  more  likely  than  in  others  to  meet  with 
disorders  of  menstruation,  as  well  as  practices  of  self-abuse,  and 
further,  inasmuch  as  the  years  from  18  to  25  are  those  which  furnish 


THE   GEX/TAf.IA    A.\/>    /.VS  IV//}'. 


the  greater  number  of  insane  inmates  of  a,sylums,  amongst  whom 
amenorrhcea  and  dysmeuorrhcea  are  very  common  coniphcations,  it  is 
essential,  if  we  would  prevent  the  more  serious  developments  of 
morbid  mentalization,  that  the  earlier,  and  oftentimes  subtle,  warn- 
ings should  be  recognized.  It  is  unfortunately  only  too  often  the 
case  that  those  traits  of  character  which  are  ascribed  to  some 
peculiarity  of  disposition  or  temperament  are  in  reality  the  first 
beginnings  of  a  morbid  train  of  ideas,  which  eventually  terminate 
in  a  mental  breakdown.  ]NIore  likely  is  this  to  occur  if  there  be 
some  sexual  fault,  some  error  in  function,  or  congenital  or  patho- 
logical abnormality  in  the  generative  organs.  Though  in  numbers 
of  ca-ses  no  prevision  nor  preventive  precautions  can  avert  the  mental 
catastrophe,  yet  will  our  recompense  be  sufficient,  even  if  we  can 
save  one  life  from  the  stamp  and  doom  of  lunacy.  Be  it  noticed 
also  that  it  is  often  the  brightest,  quickest,  and  most  apt  in  games 
and  accomplishments  during  growing  youth  who  succumb  during 
adolescence  to  those  predisposing  influences  of  inherited  tendencies, 
passions,  and  apprehensions  which  are  the  forerunners  of  delusional 
insanity. 

Question  of  Examination  and  Operation. — There  are  questions 
bearing  upon  the  entire  subject  which  are  worthy  of  consideration. 
These  are — ( aj  What  are  the  indications  for  a  gynaecological  ex- 
amination of  women  wh(5  are  suffering  from  any  form  of  mental 
aberration,  and  under  what  circumstances  is  such  examination  of 
an  insane  woman  expedient  and  justifiable?  (b)  Is  operative  inter- 
ference in  cases  of  pathological  changes  in  the  genitalia  of  insane 
women  justifiable,  and  under  what  circumstances?  ( c)  Do  opera- 
tions on  the  female  genitalia  specially  predispose  to  post-operative 
insanity,  and  in  what  cases  is  such  predisposition  most  likely  to  be 
manifested  ?  Also,  do  operations  on  the  genitalia  of  insane  women 
tend  to  aggravate  the  mental  symptoms  ? 

The  following  conclusions  are  in  accordance  with  the  evidence 
collected  from  a  large  number  of  alienists  and  gynaecologists. 

1.  Where,  in  an  insane  person,  ovulation  and  its  external  manifestation, 
the  menstrual  discharge,  are  absent  or  erratic,  the  erraticism  or  absence  may 
be  a  consequence  of  the  general  and  insane  condition,  and  not  a  causal  factor 
in  its  production  ;  but  under  any  circumstances  such  abnormal  menstruation 
appears  to  have  an  aggravating  effect  on  the  insanity,  and  there  is  sufiBcient 
evidence  to  strengthen  the  belief  that  when  such  irregularity  exists — espe- 
cially if  it  be  due  to  a  pathological  cause — it  should  be  treated  therapeutically 
or  by  operative  measures. 

"2.  The  ijuestion  of  a  gynaecological  examination  of  an  insane  woman  must 

Q 


226  DISEASES   OF    WOMEN. 

be  a  matter  for  the  discretion  of  the  ps^^chologist,  influenced  by  the  gynaeco- 
logical view  as  to  its  expediency  from  the  signs  and  symptoms  present  in  the 
sexual  organs.  For  many  reasons,  as  a  universal  practice,  in  the  present 
state  of  our  knoAvledge  it  is  not  warrantable. 

3.  SufBcient  evidence  is  now  advanced  to  justify  the  removal  of  the  adnexa 
or  tumours  of  the  uterus  in  insane  women,  when  there  are  gross  lesions  of 
the  former  or  tumours  of  the  latter.  Here,  again,  such  operations  must  be 
advised  according  to  the  psychological  condition  of  the  patient  and  the  type 
of  her  insanity. 

4.  From  a  mass  of  evidence,  including  some  of  the  largest  experiences  in 
Europe,  Canada,  and  America,  it  does  not  appear  that  there  is  in  healthfully 
minded  women,  who  suffer  from  diseases  of  the  genitalia,  any  special  risk  of 
post-operative  insanity.  On  the  other  hand,  if  there  be  a  psychopathic  pre- 
disposition, which  has  existed  prior  to  and  independently  of  the  sexual 
disease,  there  is  in  such  cases  a  larger  percentage  of  post-operative  mental 
disturbance  than  follows  other  operations.  In  such  women  the  prudence  of 
a  radical  operation  may  have  to  be  carefully  discussed.  The  post- operative 
mental  effect  does  not  appear  generally  to  be  of  a  serious  or  permanent 
nature. 

5.  It  may  be  generally  affirmed  that  when  mental  disease  of  a  graver  type 
follows  upon  sexual  disorder,  there  has  been  in  the  woman  affected  an  under- 
l^ang  and  often  unrecognized  psychopathic  predisposition ;  the  disorder  of 
menstruation  or  the  disease  in  the  genitalia  completing  the  chain  of  the 
vicious  circle  needful  for  the  final  manifestation  of  the  mental  condition. 

G.  The  relation  of  aberrant  sexual  function  or  a  disorder  of  menstruation 
to  any  criminal  act  ought  to  be  taken  into  consideration  in  determining  the 
responsibility  of  the  woman. 

It  is  well  to  keep  quite  distinct  that  numerous  class  of  cases  with 
whicli  we  are  all  familiar,  where  an  absence,  diminution,  or  ex- 
aggeration in  the  genital  function,  whether  associated  or  not  with 
some  congenital  or  pathological  condition  of  any  of  the  organs,  is 
attended  by  some  abnormal  reflex  excitation  of  one  or  more  of  the 
viscera,  or  a  peripheral  irritation  in  a  special  sense  organ,  such 
visceral  neuroses  and  reflex  disturbances,  with  their  attendant  vaso- 
motor and  vascular  changes,  being  the  more  prominent  troubles  for 
which  advice  is  sought. 

It  is  not  uncommon  to  find  some  phase  of  neurasthenia,  hypochondriasis, 
or  mild  type  of  melancholia  present,  and,  speaking  generallj',  the  neurotic 
temperament.  AH  these  various  hystero-neuroses  have  been  frequently 
Avritten  about  since  Tilt  in  England,  Fordyce  Barker  and  Engelmann  in 
Arnerica,  Shrceder  and  Hegar  in  Germany,  insisted  on  their  dependence 
upon  some  uterine  or  ovarian  affection.  It  has,  however,  to  be  remembered 
that  a  large  number  of  women  find  their  way  into  asylums  who  have  never 
consulted  a  gynajcologist,  yet  who  suffer  from  various  diseases  of  the  genitalia, 
and  disorders  of  menstruation.  And  this -fact  will,  of  course,  largely  influence 
any  conclusion  arrived  at  from  a  gynaecological  record  alone. 


THE  GENITALIA   AND    INSANITY.  227 

Joseph  Wiglesworth,  as  far  back  as  January,  1885,*  showed  the  condition 
of  the  uterus  and  its  appendages  in  109  insane  individuals,  as  ascertained  by 
examination  after  death.  This  is  a  most  complete  table,  giving  the  age, 
social  state,  form  of  mental  disorder  and  its  duration,  with  the  cause  of  death , 
and  the  condition  of  the  uterus  and  the  appendages  as  found  at  the  autopsy. 
In  a  second  table  he  shows  the  condition  of  the  uterus  and  its  appendages  in 
sixty-five  insane  patients,  as  ascertained  by  examination  during  life.  Out  of 
the  109  autopsies,  in  5"50  per  cent,  fibromata  were  found.  In  two  of  these 
they  reached  considerable  size,  and  '  there  was  evidence  derived  from  the 
history  of  the  patients,  and  the  mental  symptoms,  that  the  tumours  were 
important  contributory  factors  in  the  })roduction  of  the  melancholia  from 
which  both  patients  suffered.'  Of  the  sixty-five  cases  examined  during  life. 
two  had  fibroid  tumours  of  the  uterus.  In  one,  the  correlation  between  the 
tumour  and  the  sexual  delusions  from  which  the  patient  suffered  was  not 
established  from  the  duration  of  the  mental  affection  ;  in  the  other  there  were 
delusions  as  to  torture  inflicted  by  instruments  introduced  into  her  womb. 
'  These  delusions  have  existed  for  two  or  three  years  at  least,  and  appear  clearly 
to  depend  upon  the  growth  of  a  fibroid  tumour  in  the  fundus  of  the  uterus. 
Though  the  tumour  is  not  at  present  producing  any  marked  physical  effects, 
it  is  legitimate  to  inquire  whether  operative  interference  might  not  be  justified, 
in  order  to  rid  the  patient  of  what  seems  to  be  such  a  source  of  misery  to  her.' 

[There  can  be  now  no  doubt  that  hysterectomy  would  have  been  justifiable 
in  such  a  case.] 

Rohe,  in  the  Maryland  Hospital,  and  Hobbs,  of  Ontario, 
during  live  years  had  800  insane  women  under  observation,  and 
of  these  220  were  examined  by  a  gynaecologist.  One  hundred  and 
eighty-eight,  or  85  per  cent.,  of  those  examined  had  distinct, 
and  in  many  cases  serious,  lesions  of  the  pehic  organs,  there 
being  371  lesions  in  the  188  patients.  It  is  interesting  to  note 
the  nature  of  these  lesions  —  subinvolution  or  endometritis  in 
132,  diseased  or  lacerated  cervices  in  62,  retroversion  or  prolapsus 
in  66,  myomata  in  16,  malignancy  in  2,  disease  of  the  adnexa  in 
33,  various  lesions  of  the  vagina  in  37.  Eighteen  women  suffered 
from  dysmenorrhcea  or  menorrhagia.  These  of  course  were  cases 
specially  selected  as  likely  sufferers  from  pelvic  disease,  and  w^ere 
about  25  per  cent,  of  the  entire  number  of  patients  in  residence 
during  the  time  in  which  these  investigations  were  conducted. 
There  were  311  operations  performed  on  the  173  women,  as  follows  : — 
A  hundred  and  thii-ty-one  curettings,  53  trachelorrhaphies,  or 
amputations  of  the  cervix,  37  Alexander's  operations,  13  ventro- 
fixations,  27  perineorrhaphies,  22  ovariotomies,  14  abdominal  and  9 
vaginal  hystei'ectomies,  3  myomectomies,  and  2  cceliotomies  for 
tuberculous  peritonitis.     Without  going  into  details,  the  summary 

*  *  Uterine  Disease  and  Insanity,'  Journal  of  Mental  Science,  January.  ISS.^. 


228  DISEASES    OF   WOMEN. 

of  the  results  of  operation  in  these  cases  is  as  follows  : — Seventy- 
three,  or  42  per  cent.,  recovered  mentally  ;  forty -one,  or  24  per  cent., 
were  improved  mentally;  in  fifty-five,  or  32  per  cent.,  there  was 
no  change  in  the  mental  condition  ;  and  four,  or  2  per  cent.,  died. 
Hobbs  appends  some  most  striking  instances  of  rapid  recovery  after 
the  gyngecological  operations.  He  is  not  oblivious  to  the  obvious 
criticism  on  such  statistics,  that  a  certain  proportion  of  these  women 
would  have  recovered  from  the  disordered  mental  state  without  any 
operation. 

He  contends  that,  taking  eight  years  in  the  history  of  the  asylum, 
the  introduction  of  gynaecological  surgery  as  an  adjunct  of  treat- 
ment has  improved  the  percentage  of  recoveries,  from  33  per  cent, 
to  51  per  cent,  on  the  admissions;  and  he  compares  the  results 
following  from  cure  of  the  affections  of  the  sexual  organs  with 
recovery  resulting  from  the  surgical  treatment  of  inguinal  hernia 
by  the  Bassini  method  in  23  cases,  as  in  the  latter  no  improvement 
in  the  mental  condition  followed,  though  the  subsequent  nursing  of 
the  patient  was  the  same  in  both  instances.  Another  interesting 
point  that  Hobbs  dwells  on  is  a  comparison  of  the  relative  import- 
ance of  the  various  sexual  lesions  in  the  production  or  maintenance 
of  cerebral  disturbance.  Of  the  inflammatory  utero-ovarian  affec- 
tions, in  96  cases  treated  the  recovery  was  50  per  cent. ;  in  47  cases 
of  utero-ovarian  displacements  corrected,  there  was  36  per  cent,  of 
recoveries ;  and  in  non-inflammatory  utero-ovarian  and  vaginal 
lesions,  there  was  26  per  cent,  of  recovery.  In  no  instance  did  the 
administration  of  an  anaesthetic  in  the  600  anaesthetizations  make 
any  difference  in  the  mental  state  of  a  patient.  They  were  neither 
better  nor  worse,  Ernest  Hall  *  gives  a  table  of  75  cases  of  insanity 
in  women,  in  whom  in  only  4  cases  examination  failed  to  detect 
some  affection  of  the  sexual  organs.  In  21  of  the  entire  number 
there  was  a  previous  history  of  pelvic  disease,  and  on  examining 
the  nature  of  the  affection  present  in  these  71  women,  one  is  struck 
by  the  fact  that  only  one  instance  of  uterine  myoma  or  other  uterine 
tumour  is  recorded.  By  far  the  larger  proportion  suffered  from 
lacerations  of  the  perineum  and  cervix  uteri,  or  displacements  of  the 
uterus,  tumours,  and  chronic  inflammatory  conditions  of  the  adnexa.t 

Hall  gives  the  results  of  operative  treatment  in  38  cases  of 
insanity.     In  some  the  operations  were  of  a  complex  character — as, 

*  Pacific  Medical  Journal,  April,  1900. 

t  See  also  communication  by  the  Baine  author  in  the  Brit.  Gynsec.  Journ. 
Nov.,  1900  :  '  The  Gynaecological  Treatment  of  the  Insane.' 


THE   GENITALIA   AND  INSANITY.  229 


for  example,  removal  of  the  appendages  and  ventro-fixation,  ampu- 
tation of  the  cervix,  oophorectomy,  and  ventro-fixation.  The  opera- 
tions thus  performed  were — Curettage,  9  ;  operations  on  the  cervix, 
as  amputation  of  the  cervix  and  trachelorrhaphy,  with  perineor- 
rhaphy, 11;  oophorectomy  and  salpingo-oophorectomy,  20  ;  resection 
of  the  ovaries,  10;  salpingotomy,  1  ;  ventro-fixation,  9;  supra- 
vaginal hysterectomy,  1  ;  vaginal  hysterectomy,  1 ;  colpotomy,  2  ; 
haemorrhoids,  1.  Out  of  the  75  cases,  only  2  had  had  a  previous 
gynaecological  examination.  Of  those  operated  upon,  we  can  classify 
the  results  as  follows: — 6  complete  recoveries,  7  partial  improve- 
ments, 3  temporary  improvements,  9  slight  improvements,  and  5 
negative  results.  One  case  of  acute  mania  died  nine  weeks  after 
the  operation,  from  meningitis  :  1  died  nine  days  after  operation, 
from  meningeal  congestion  and  septicaemia ;  1  died  nineteen  days 
after  operation,  from  the  bursting  of  a  secondary  abscess  into  the 
peritoneal  cavity  ;  one  died  on  the  eighteenth  day  after  operation, 
namely,  a  case  of  curettage,  with  suspension  of  the  left  ovary  and 
ventro-fixation  :  there  was  no  post-mortem. 

Mary  Dixon  Jones  mentions,  from  evidence  she  has  collected,  that 
salpingo-oophorectomy  or  oophorectomy  was  successfully  performed 
on  eighteen  women  for  affections  of  the  nervous  system,  with  the 
result  of  a  complete  cure.  Rone  (one  of  the  first  psychologists  who 
insisted  on  the  correlation  of  genital  disease  and  insanity),  George 
Engelmann,  Roke  Ley,  Lapthorn  Smith,  and  others,  have  collected 
evidence  showing  the  same  correlation.  Striking  individual  examples 
have  been  published  by  Japp  Sinclair,  Christopher  Martin,  and 
Halliday  Croom.  In  three  cases  complete  recovery  followed 
operation. 

Roke  Ley  urges  "that  uterine  displacements  and  tumours  do 
undoubtedly  cause  and  perpetuate  mental  disorders,  and  induce 
delusions  referred  to  the  neighbourhood  of  these  organs,  and  that 
ovarian  tumours  act  in  a  similar  way."  Amongst  psychological 
authorities  in  England  there  is  considerable  scepticism  as  to  the 
benefit  to  be  derived  from  operative  interference.  There  is,  however, 
no  bias  or  prejudice,  but  an  open  mind,  in  regard  to  the  question. 

Willi  regard  to  the  question,  Do  gynsecological  ojyerations  predispose 
to  insanity  ?  I  have  drawn  on  the  experience  of  some  of  the  greatest 
of  living  operators.  The  conclusion,  almost  universally  expressed, 
is  that  stated  almost  in  the  same  words  by  A.  Martin  *  and 
Schauta.*     The  view  of  the  former  I  have  already  given.     Schauta 

*  Communications  to  the  author. 


230  DISEASES   OF   WOMEN. 


says  :  '  I  never  saw,  in  a  healthy  woman,  any  disturbance  of  mind 
after  an  operation.  .  .  .  There  is  always  '  (in  such  a  case)  '  some 
predisposition.'  *  '  I  have  not,'  says  Hegar,*  '  observed  any  psychosis 
succeeding  an  antecedent  major  operation  on  the  female  genitalia.' 
'  In  over  4000  operations  on  women,'  says  Lapthorn  Smith,*  '  of 
which  over  500  were  abdominal  sections,  there  was  not  a  single 
case  of  insanity  following  the  operation.'  Christian  Simpson  quotes 
Homans  as  having  two  cases  in  1000  laparotomies,  including  several 
hundred  ovariotomies  and  hysterectomies.  Lawson  Tait  had  no 
case  of  insanity  in  his  practice  up  to  1890.  Spencer  Wells  had  but 
two  cases  arising  out  of  ovariotomy,  and  Granville  Bantock's 
experience  coincided  with  that  of  Tait  up  to  the  same  date.  Savage 
collected  records  of  4  cases  of  insanity  out  of  483  cases  of  double 
salpingo-oophorectomies ;  and  Keith,  in  64  hysterectomies,  with 
removal  of  the  ovaries,  had  6  cases  of  insanity.  These  last  statistics 
appear  to  show  an  unusually  large  proportion,  but  it  has  to  be 
remembered  that  septic  conditions  exert  a  marked  influence  in  the 
production  of  post-operative  mental  disturbance,  and  that  those 
operations  were  performed  at  a  time  when  the  mortality  was  large 
from  septicaemia,  and  septic  complications  even  in  those  who  re- 
covered were  not  infrequent.  I  have  never  seen  any  injurious 
mental  consequence  follow  a  gynaecological  operation  in  a  healthy 
woman ;  and  in  the  only  two  in  whom  symptoms  of  post-operative 
insanity  appeared,  one  had  previously  been  in  an  asylum,  and  the 
other,  an  official  in  a  private  one,  had  been  a  typical  neurasthenic 
for  some  years. 

Indications  for  Examination. — With  regard  to  the  indications  for, 
and  the  circumstances  under  which,  a  gynaecological  examination  of 
an  insane  woman  is  expedient  and  justifiable,  Robert  Barnes  advo- 
cated the  elimination,  by  examination  if  necessary,  of  the  presence 
of  any  sexual  disorder  in  a  woman  before  confining  her  to  an  asylum. 
That  this  is  a  rational  conclusion,  in  view  of  our  present  knowledge, 
is,  I  think,  clear.  It  does  not  necessarily  involve  an  internal 
examination  of  the  genitalia ;  for  an  inquiry  into  the  past  history  of 
the  patient,  together  with  the  circumstances  under  which  the  first 
evidences  of  alienation  appeared,  will  generally  enable  us  to  exclude 
the  possibility  of  there  being  any  interference  with  the  discharge  of 
the  functions  of  her  sexual  organs.  Such  an  inquiry  will  also  assist 
us  in  arriving  at  the  conclusion  that  symptoms  of  mental  disturb- 
ance preceded  any  interferences  of  function,  or  vice  versa. 
*  Communications  to  the  author. 


THE   <;E.\ITM.t.\    .\\l>    IS.^ANITV.  281 


Such  a  careful  investigation  giving  us  negative  results,  will  influence  us 
against  the  necessity  for  jirocoediiig  further.  Also,  obviously,  in  a  fair  pi-o- 
portion  of  cases  there  will  be  within  our  knowledge  other  causes  preilisposiiig 
to  and  producing  the  insanity.  Take,  for  example,  the  frequently  occurring 
one  of  heart  disease  as  a  physical,  and  disappointment  in  love  affairs  or 
mental  worry,  as  a  psychical,  cause.  Or  again,  we  may  verify  the  habit  of 
masturbation.  Such  careful  impiiry  will  also  elicit  the  proofs,  both  by 
symptoms  and  signs,  of  previous  pelvic  disease,  whether  in  the  uterus, 
adnexa,  or  external  genitalia.  Should  this  exist,  we  have  a  clear  indication 
for  the  determination  of  the  extent  and  nature  of  the  disease,  and  its  pro- 
bable effect  on  the  mental  condition.  The  age  of  the  patient,  and  her  state, 
whether  married  or  single,  will  influence  us.  The  disorders  of  menstruation, 
so  frequent  during  the  years  of  adolescence,  have  commonly  no  local  patho- 
logical explanation.  We  have,  however,  to  remember  that  the  causes  of 
these  are  often  congenita).  A  persistent  dj^smenorrhoea,  menorrhagia,  or 
metrorrhagia  would  certainly  indicate  the  need  for  examination,  as  would  a 
suspicion  that  the  uterus  was  retroverted.  Permanent  amenorrhcea  would 
arouse  suspicion  of  atresia  of  either  uterus  or  vagina,  and  the  possibility 
of  partial  or  complete  absence  of  the  genitalia  has  to  be  recollected.  In 
married  women  there  is  not  the  same  reluctance  to  examination;  the 
causes  of  disorders  of  menstruation  are  more  likely  to  be  pathological ;  and 
consequently  the  indications  for  examination  are  generally  more  obvious. 
During  middle  life  also  we  have  all  the  parturient  and  puerperal  sources  of 
insanity  requiring  investigation.  At  the  advent  of  and  during  the  meno- 
pause, should  any  striking  deviation  from  the  natural  course  of  cessation  of 
menstruation  precede  or  accompany  the  insanitj^,  an  examination  should  be 
made,  for  the  same  reason  that  we  advise  it  in  ordinary  cases,  namelv,  to 
escape  the  error  of  overlooking  any  serious  pathological  condition  of  the 
adnexa  and  uterus.  This  being  so  in  the  case  of  the  sane  woman,  it  is  even 
more  so  in  the  case  of  the  insane,  where  we  have  the  additional  reason  of 
the  mental  condition  being  atti'ibutable  to  any  disease  that  may  be  present. 

Indications  for  Operation. — With  regard  to  the  question  of 
operative  interference  in  cases  of  pathological  changes  in  the  genitalia 
of  insane  ■women,  all  the  evidence  before  us,  of  which  there  is  no 
reason  to  doubt  the  accuracy,  shows  that  such  interference  is  called 
for — (a)  When,  on  weighing  the  etiological  factors  in  the  causation 
of  any  particular  case,  they  point  to  a  causal  relationship  between 
the  sexual  disorder  and  the  disturbance  of  mentalization.  (h)  When 
observation  of  the  patient  shows  that  the  pelvic  disorder  aggravates 
the  insanity  by  intensifying  delusions,  directing  the  mind  morbidly 
to  the  sexual  organs,  increasing  the  severity  of  periodical  outbursts, 
or  by  their  influence  on  the  physical  well-being  preventing  improve- 
ment of  the  mental  state.  It  is  for  the  psychologist  to  decide  the 
most  favourable  time  for  operation,  and  the  contra-indication  that 
may  be  presented  by  the  phase  and  type  of  the  insanity. 


232  DISEASES    OF    WOMEN. 

Lastly,  with  regard  to  the  third  point  raised,  as  to  the  occurrence 
of  post-operative  insanity  after  gynaecological  operations,  I  have 
already  answered  this  question.  It  certainly  does  not  appear,  from 
the  published  records  of  operations  performed  on  the  insane,  that 
the  symptoms  have  been  thereby  aggravated,  save  in  very  few 
instances,  and  in  these  the  effect  does  not  seem  to  have  been 
permanent. 

Use  of  Ovarine  in.  Sexual  Insanity — As  stated  in  the  text,  the  ovarian 
secretion  has  been  used  largely  for  the  various  symptoms  arising  after  removal 
of  the  ovaries,  and  has  also  been  employed  in  many  cases  of  dysmenorrhoea, 
amenorrhcea,  and  anaemia  arising  out  of  affections  of  the  ovaries.  Mainzer 
at  Berlin,  Chrobak  at  Vienna,  Muret  at  Lausanne,  Jayle  in  Paris,  were 
amongst  the  first  who  employed  the  ovarian  secretion  in  these  functional 
disorders  of  menstruation,  both  in  the  induced  and  prematurely  occurring 
climacteric,  and  various  cases  have  been  reported  of  benefit  consequent  upon 
its  administration  in  such  affections.  No  evil  results  have  followed  from  its 
use.  The  method  of  administration  recommended  is  the  ovarine  powder, 
after  desiccation,  either  in  cachet,  tablet,  pills,  or,  preferably,  as  palatinoids. 

In  an  extensive  critical  review  of  the  entire  subject  of  the  internal  secre- 
tion of  the  ovary,*  Henry  Russell  Andrews  epitomises  the  results  of  the 
experiments  which  have  been  made  by  Neumann,  Curatulo,  Tarulli,  and 
Falk,  and  also  the  question  of  a  ganglionic  plexus  and  ganglion,  as  discussed 
by  Elizabeth  Winterhalter  and  von  Herff.  He  summarizes  the  result  of 
ovarian  medication  as  practised  by  Brown  Sequard,  Mainzer,  L.  Landau, 
Bodon,  Jayle,  and  others,  up  to  the  time  of  Bastion  de  Camboulas  in  1898, 
and  Cohn  and  Seeligmann  to  Flockemann  in  190L  From  the  reports  of 
some  of  these  authorities  it  would  certainly  appear  that  the  ovarian  secretion 
has  a  good  effect  in  affections  of  the  climacteric,  and,  to  a  less  extent,  in 
chlorosis  and  amenorrhcea.  It  has  been  given  in  this  country  mainly  in  the 
forms  above  mentioned,  and  abroad  as  fresh  gland,  the  ovaries  being  minced 
and  given  in  sandwiches — a  very  difficult  method,  not  only  from  its  repug- 
nancy, but  from  the  impossibility  of  keeping  them  fresh.  It  has  also  been 
administered  in  form  of  a  powder  of  the  dry  gland  under  different  names, 
and,  as  juice  or  fluid  extract,  watery  glycerinated,  or  alcoholic.  The  most 
active  ovaries  are  those  of  the  sow.  Those  of  heifers  are  not  so  active,  and 
cows  are  liable  to  tubercle.  I  have  for  some  years  been  administering 
ovarine  in  tabloid  or  palatinoid  form,  but  I  cannot  speak  with  confidence  of 
their  permanent  effects  when  taken  without  any  other  agent.  The  influence 
of  transplantation  of  the  ovary  on  menstruation  has  already  been  discussed. 

*  '  The  Internal  Secretion  of  the  Ovary,'  H.  Eussell  Andrews,  Jour.  Obstet. 
andGyn.  Brit.  Emp.,  May,  1904. 


CHAPTER   XI. 
UTERINE   DISPLACEMENTS. 

Important  Displacements. 

Anteversion. 

Retroversion  and  Retroflexion. 

Prolapse. 

Ascent. 

Inversion. 

Anteversion. 

As  the  uterus  in  the  normal  condition  lies  anteverted  in  the  pelvic 
cavity  (Fig.  158),  it  is  not,  strictly  speaking,  correct  to  regard 
"  anteversion"  as  a  "  displacement.  Owing  to  pressure  from  above, 
or  posteriorly,  or  from  the  yielding  of  its  supports,  above,  below,  or 
at  the  side,  or  from  contractions  or  adhesions  which  drag  on  it 
anteriorly,  the  fundus  uteri  is  thrown  further  downwards  and 
forwards  in  the  pelvis.  Ultimately  it  is  so  far  displ<iced  out  of  its 
proper  axis  to  the  peh~ic  brim  that  it  rests  against  the  bladder, 
while  the  os  uteri  is  carried  back 
towards  the  pouch  of  Douglas.  As 
we  might  suspect  from  the  normal 
inclination  of  the  uterus,  and  the 
influences  which  operate  in  pro- 
ducing an  exaggeration  of  it,  we 
tind  this  a  common  uterine  dis- 
placement.    In    its  worst  form    it 

is  most  distressing  to  the  patient,  *  \^ 

and  difficult  to  relieve.  P^^   158.-Degrees  ..f  Antk^'' 

Any  of  the  afiections  I  have  just  veksiox. 

grouped    as    consequences    of    dis- 
placements may  result  from  extreme  anteversion.     Those  that  are 
found  as  the  most  frequent  attendants  on  it  are — amenorrhcea  and 
dysmenorrhoea,  uterine  congestion,  uterine  fibroid,  stenosis,  sterility, 


234  DISEASES   OF   WOMEN. 

vesical  and  rectal  distress,  uterine  prolapse,  locomotor  symptoms, 
sacral  and  lumbar  pains,  ovarian  congestion,  and  ovaritis.  It  is  a 
safe  maxim  in  gynsecological  practice  to  look  outside  the  bladder  itself 
for  the  cause  in  any  case  ivhere  there  is  difficulty  before  or  during  the 
act  of  micturition,  or  evidence  of  retention  of  urine.  We  shall  very 
frequently  find  it  in  an  anteflexed  or  retroverted  uterus.  In  like 
manner,  when  there  is  tenesmus,  or  a  sense  of  pressure  in  the 
rectum  and  general  rectal  distress,  with  the  passage  of  faeces  which 
are  in  form  suggestive  of  stricture,  we  may  discover  the  cause  in 
uterine  displacement. 

Diag'nosis. — If  we  suspect  the  malposition,  there  is  no  difficulty 
in  quickly  verifying  our  suspicions.  We  might,  if  careless,  confound 
both  anteversion  and  anteflexion  with  a  fibroid  of  the  uterus,  or  a  vesical 
tumour.  We  are  liable  to  overlook  the  pathological  condition 
attendant  upon  or  preceding  the  version — as,  for  example,  an  intra- 
mural fibroid,  subinvolution  of  the  uterus,  simple  hypertrophy,  an  intra- 
uterine polypus,  adhesions,  metritis  or  perimetritis.  While  we  may 
therefore  prove  satisfactorily  that  the  uterus  is  ante  verted  or  ante- 
flexed,  we  must,  by  a  searching  digital  and  bimanual  examination 
in  the  manner  previously  described,  and  with  the  sound  if  necessary, 
exclude  any  possibility  of  such  complications  being  present.  By 
digital  examination,  the  absence  of  the  cervix  from  the  fornix  of 
the  vagina,  its  position  posteriorly  in  the  sacral  hollow,  and  the 
detection  anteriorly  of  the  hard  fundus  (less  so  in  the  dorsal 
decubitus)  will  show  that  the  uterus  is  anteverted.  By  abdomino- 
vaginal examination  we  can  get  the  entire  organ  between  our 
hands,  and  satisfy  ourselves  that  the  mass  which  is  felt  anteriorly  is 
the  fundus  uteri.  If  there  should  be  still  a  doubt  or  suspicion  of 
other  complications,  it  may  be  necessary  to  complete  the  diagnosis 
with  the  sound. 

I  repeat  here  the  obstetric  axiom  —  Do  not  take  the  uterine  sound 
in  hand  in  any  case  in  tuhich  there-  is  a  suspicion  of  jpreg7iancy.  Most 
necessary  is  it  to  recollect  this  rule  ia  the  instance  of  an  enlarged  and  ante- 
verted uterus.  Should  the  possibility  of  pregnancy  be  exckided,  more  espe- 
cially if  we  desire  to  use  the  sound  both  for  a  diagnostic  and  therapeutic 
purpose,  we  may  pass  it.  This,  at  times,  is  not  such  an  easy  operation.  It 
may  be  difficult,  even  when  the  sound  is  well  curved,  to  get  it  into  the  os 
uteri  in  extreme  anteversion.  Some  old  flexion  may  impede  its  progress  ;  so 
may  also  a  uterine  growth.  The  important  lesson  we  must  learn  is,  to  use 
no  force  in  the  attempt.  By  carrying  the  handle  well  back,  or  by  giving  the 
instrument  various  degrees  of  curvature,  we  shall  succeed  by  gentleness  and 
not  by  force. 


UTEBINE  DISPLACEMENTS.  -ias 


Treatment. — Having  determined  the  degree  of  mobility  of  the 
uterus,  we  can,  with  the  fingers  of  the  right  hand  carried  deeply 
behind  the  pubes,  press  the  fundus  upwards  and  backwards,  while 
at  the  same  time  we  steady  the  cervix  with  a  linger  of  the  left 
hand  in  the  vagina,  and  draw  it  forwards.  Should  the  uterus  be 
so  fixed  that  we  cannot  succeed  in  this  manojuvre  by  the  fingers,  it 
is  seldom  that  we  can  safely  effect  much  greater  permanent  improve- 
ment in  position  by  the  sound.  Recollecting  the  etiology  of  ante- 
version,  it  is  obvious  that  the  mere  reposition  of  the  uterus  is 
frequently  the  least  part  of  the  practitioner's  duty.  The  general 
health  of  the  woman  must  be  carefully  attended  to,  and  her 
secretions  regulated ;  congested  and  hypertrophic  conditions  of  the 
uterus,  contractions  of  the  cervical  canal,  any  complicating  tumour 
or  eiTusion,  ought,  as  far  as  possible,  to  be  rectified,  and  any  ab- 
dominal pressure  relieved.  In  the  meantime,  we  endeavour  to  raise 
the  fundus  uteri,  and  retain  it  in  position  by  a  pessary  ;  and  the  best 
T  know  of  is  that  of  Galabin  (Fig.  159). 

It  must  be  clearly  understood  that  all  these  remarks  refer  io  an 
extreme  degree  of  this  form  of  uterine  displacement. 

'  I  have  learned,'  says  Goodell, '  to  unlearn  that  anteflexion  and  anteversion 
in  themselves — that  is  to  say,  as  displacements  merely,  and  without  narrow- 
ing of  the  uterine  canal — are  necessarily  pathological  conditions  of  the  womb. 
The  mistake  made,  as  I  have  more  elaborately  shown  in  my  "  Lessons  on 
Gynaecology,"  is  in  attributing  to  this  natural  position  of  the  womb  the  various 
forms  of  pelvic  trouble,  especially  that  of  irritability  of  the  bladder,  to  which 
women  are  so  liable.  But  the  sympathy  between  the  brain  and  the  bladder 
is  a  remarkably  close  one — so  close,  indeed,  that  some  physiologists  contend 
that  "  every  mental  act  is  accompanied  by  a  contraction  of  the  bladder."  A 
nervous  bladder  is,  then,  one  of  the  earliest  phenomena  of  a  nervous  brain, 
for  nervousness  means  a  deficient  control  of  the  higher  nerve-centres  above 
the  lower  ones — a  lack  of  brain  control.  Now,  a  hysterical  girl,  or  a  woman 
whose  nervous  system  has  given  way  under  the  strain  of  domestic  cares,  con- 
sults the  physician  for  such  ordinary  sj^mptoms  of  nerve-exhaustion  as  wake- 
fulness, utter  weariness,  a  bearing-down  feeling,  backache,  and  perhaps, 
above  all,  an  irritable  bladder.  Upon  making  a  digital  examination,  he 
usually  finds  the  fundus  of  the  womb  resting  on  the  bladder,  where  it  natu- 
rally should  rest.  At  once  he  jumps  to  the  conclusion  that  the  whole  trouble 
is  due  to  pressure  of  the  womb  on  the  bladder — viz.,  to  the  existing  natural 
anteversion,  or  to  the  anteflexion,  as  the  case  may  be.  Enticed  away  by  the 
vesical  lapwing  from  the  bottom  factor- — the  shattered  nerves — he  now  makes 
local  applications,  and  racks  his  brains  to  adapt  or  devise  some  pessary  capable 
of  overcoming  the  supposed  difficulty,  heedless  of  the  dilemma  that  the  upward, 
or  shoring,  pressure  of  the  pessary  on  the  bladder  must  be  gi-eater  than  the 
counter,  or  do^\Tiward,  pressure  of  the  womb,  to  which  he  attributes  the  vesical 
instability.' 


236  DISEASES   OF   WOMEN, 

Pessaries. — While  the  rash  or  indiscriminate  use  of  pessaries  is 
to  be  strongly  condemned,  I  desire,  on  the  other  hand,  not  to  be 
understood  as  undervaluing  the  assistance  in  treatment  we  obtain 
through  the  well-adjusted  pessary.  In  all  forms  of  displacement 
where  its  employment  is  clearly  indicated,  it  generally  gives  material 
relief.  I  know  few  steps  in  gynfecological  therapeutics  attended 
with  such  obvious  and  immediate  benefit  and  comfort  to  a  patient 
as  the  restoration  of  a  retroverted  uterus  to  its  normal  position,  and 
its  support  and  retention  by  a  well-fitting  pessary.  In  the  same 
manner,  in  the  varying  degrees  of  descent  of  the  uterus  which  more 
or  less  accompany  all  versions  and  flexions,  "with  a  pessary  suited  to 
the  case  we  immediately  secure  that  sense  of  support,  and  prevent 
the  bearing-down  feeling  and  associated  pain  which  are  so  distress- 
ing. By  replacement  of  the  uterus,  the  use  of  a  pessary,  and  the 
adoption  of  the  postural  plan  and  periodical  reposition  in  the  knee- 
elbow  position,  in  cases  of  retroversion  the  uterus  and  its  supports 
can  be  restored  to  a  healthy  state,  so  as  in  time  to  obviate  the 
necessity  for  any  mechanical  appliance.  In  graver  degrees  of 
displacement  a  mechanical  support  is  a  tedious  and  frequently 
disappointing  mode  of  treatment,  and  ventro-fixation,  ventro-sus- 
pension,  or  shortening  of  the  round  ligaments,  is  the  quickest  way 
to  restore  the  woman  to  health  and  strength. 

There  are  some  safe  rules  to  observe  in  regard  to  the  use  of 
pessaries  : — 

1.  Always,  by  the  vaginal  and  recto-vaginal  methods  in  tlie  dorsal  and 
lateral  positions,  make  a  careful  digital  exploration  of  the  vagina  and  uterus 
before  their  application  (the  rectum  and  bladder  being  empty). 

2.  In  anteversion  and  anteflexion,  if  there  be  uterine  congestion,  sensitive- 
ness, or  enlargement,  avoid  the  use  of  a  pessaryuntQ  such  conditions  are  relieved. 

3.  The  uterus  should  be  replaced  before  introducing  any  pessary. 

4.  JVJienever  possible,  mould  and  fasMon,from  a  celluloid  ring  or  pliahle 
metal,  the  pessary  you  require,  and  regulate  its  size  a/nd  shape,  or  lever-power, 
axcording  to  tJie  degree  of  version  or  flexion,  the  tightness  of  the  vaginal  roof, 
and  the  capacity  a/ad,  muscular  tone  of  the  vagina. 

5.  Always  teach  the  patient  how  to  remove  a  pessary,  should  any  pain  or 
discomfort  arise  from  its  use.  In  many  instances  it  is  equally  easy  to  teach 
her  hoAv  to  reinsert  it ;  but,  as  a  rule,  this  should  be  done  by  the  practitioner. 

6.  See  the  patient  occasionally  at  first,  so  as  to  ensure  comfort  in  the  use 
of  the  appliance,  to  detect  any  accidental  displacement.,and  to  watch  for  any 
vaginal  irritation.  Patients  wearing  pessaries  should  be  kept  under  observa- 
tion, and  periodical  cleansing  of  the  vagina  with  a  disinfecting  sohition  pre- 
scribed. Strict  attention  must  be  paid  to  the  bladder  and  rectum.  In  the 
case  of  a  married  woman,  endeavour  always  to  select  a  pessary  that  does  not 
interfere  with  coitus. 

7.  When  adnesal  disease  is  present,  avoid  all  pessaries. 


UTERINE  DISPLACEMENTS.  237 


I  do  not  believe  that  any  verbal  description  can  teach  the  proper 
selection  or  the  correct  adjustment  of  a  pessary.  This  must  be 
learned  in  the  hospital  ward,  in  private  practice,  or  in  the  extern 
obstetric  department  of  a  hospital.  In  anteversion  our  object  is  to 
raise  the  fundus,  and  place  such  a  support  anteriorly  as  will  prevent 
it  relapsing  into  its  old  position.  In  many  cases  of  anteversion 
sufficient  support  for  the  uterus  can  be  obtained  from  a  rino- 
moulded  to  suit  the  case.  Celluloid  rings  of  different  sizes  can  be 
readily  converted  to  act  on  the  principle  of  the  Galabin,  by  dipping 
them  into  very  hot  water,  giving  any  shape  we  desire.  We  can 
rapidly  shape  from  such  rings  a  Hodge,  with  the  arms  of  the  lever 
of  any  length  or  form  we  wish.  When  the  ring  has  been  so  moulded, 
it  is  dipped  for  a  few  seconds  in  cold  water  to  set.  With  these 
rings  we  are  enabled  to  adapt,  for  the  case  before  us  at  the  time,  a 


Fig.  159.— Galabin's  Pessary.*  Fig.  160.— x^.,x^,eksiojj  Pessaky. 

Moulded  from  Schultze's  King. 

pessary  of  any  size  or  shape  we  think  applicable.  Galabin's  pessary 
I  believe  to  be  the  most  generally  useful  one  in  anteversion.  It  should 
be  inserted  and  removed  by  the  surgeon.  It  is  made  of  vulcanite 
(Fig.  159).  'In  introducing  the  instrument,  it  is  at  first  passed 
entirely  within  the  vulva,  with  the  upper  limb  in  f  I'ont  of  the  cervix ; 
the  index-finger  is  then  carried  through  it,  and  hooks  the  upper 
limb  back  over  the  cervix  and  into  the  posterior  cul-de-sac'  In 
using  this  support,  it  is  essential  to  see  that  it  fits  comfortably,  and 
is  neither  too  tight  nor  too  loose  in  the  vaginal  canal. 

Fig.  161  shows  Grailly  Hewitt's  cradle-pessary.  We  introduce  it 
by  pushing  in  the  large  ring  of  the  pessary  through  the  vulva, 
pressing  it  steadily  in  an  oblique  manner  upwards  and  backwards  ; 
the  summit  of  the  instrument  is  then  carried  into  position  in  front 
of  the  uterus,  its  lower  end  being  pushed  gently  upwards. 

The    rubber    pessary    of     Blackbee     will    be    found     easy    of 

*  I  have  ceased  to  use  any  other  pessary  in  anteversion  than  this  of  Galabin — 
unless  I  mould  a  ring  suitaVjle  for  the  case,  giving  it  a  shape  somewhat  like  a 
sledge-shaped  Schultze's, 


238  DISEASES   OF    WOMEN. 

application.     It  can  be  adapted  both  for  anteversion   and    retro- 


version. 


Fowler's  pessary  is  more  applicable  for  retroversion,  and  I  rarely 
employ  it  for  anteversion,  still,  it  will  be  found  in  both  forms  of 


Fig.  161. — Hewitt's  Pjsssakt.  Fig.  162. — Fowleh's  Pessary. 

displacement  a  safe,  easily  applied,  and  useful  pessary  by  the  general 
practitioner  (Fig.  162). 

A  caution  is  necessary  in  regard  to  this  aud  any  hollow  vulcanite  pessary. 
Should  any  small  crack  or  opening  be  made  in  the  instrument,  it  becomes 
foul  and  imprisons  decomposing  secretions.  The  principle  of  this  pessary 
can  generally  be  easily  shown  to  the  patient,  and  she  may  be  taught  how  to 
remove  and  replace  it.  This  is  not  possible  with  some  women,  and  it  should 
then  be  periodically  removed  by  the  surgeon  and  examined.  The  pessary  as 
made  by  Messrs.  Arnold  is  not  open  to  the  foregoing  objection. 

One  of  such  a  size  should  be  chosen  as  will  not  incommode  the 
cervix  or  the  vagina. 

When  the  pessary  is  in  position,  the  neck  of  the  uterus  is  received 
into  the  cup  of  the  support,  and  the  curved  anterior  portion,  ivith  the 
small  opening  for  the  finger  to  facilitate  introduction  and  removal,  lies 
in  front  of  the  uterus. 

Anteflexion. 

Anteflexion  may  be  either  congenital  or  acquired.  The  body  of 
the  uterus  is  bent  forwards  over  the  cervix,  and  the  axis  of  the 
cavity  of  the  fundus  uteri  no  longer  forms  a  continuous  and  slightly 
curved  canal  with  that  of  the  cervix,  but  is  placed  at  an  angle, 
varying  in  degree  according  to  the  extent  of  the  flexion.  The 
cervix  may  be  directed  forwards  at  various  angles,  while  the  cavity 
of  the  fundus  retains  its  normal  axis ;  or  the  flexion  may  occur  both 
in  the  body  and  neck  of  the  uterus,  an  extreme  degree  of  angular 
constriction  at  the  isthmus  uteri  resulting. 


UTEBINE   DISPLACEMENTS. 


239 


Fig.   163. — Anteflkxiux 
OF  Uterus.    (Schuoe- 

DEli.) 


The  lesions  anteversion  and  anteflexion  blend  into  one  another. 
There  has  been  a  state  of  anteversion  prior  to  the  flexion.  In 
primary  anteflexion  this  displacement  may 
not  give  much  trouble  until  after  marriage, 
when  the  increased  stimulus  to  menstruation 
excites  a  more  profuse  menstrual  discharge, 
and  the  obstruction  to  its  flow  caused  by 
the  flexion  produces  dysnienorrhcea.  On 
the  other  hand,  it  may  be  accidentally  dis- 
covered, and  should  always  be  remembered 
as  a  likely  cause  of  severe  dysmenorrhcea 
occurring  with  the  earlier  periods  in  young 
girls. 

Causation. — An  acquired  anteflexion  may 
be  induced  and  promoted  by  any  of  the 
influences  mentioned  as  tending  to  produce 
anteversion.  I  have  already  referred  to  the 
importance  of  a  free  circulation  at  the  '  axis  of  suspension '  (Barnes) 
of  the  uterus.  Obstruction  here  must  lead  to  venous  congestion, 
congestion  to  interstitial  hardening,  or  hypex'trophy,  and,  as  a  result, 
either  morbid  growths  or  secondary  contractions  are  formed.  In  no 
situation  should  we  more  naturally  expect  these  to  occur  than  in 
the  anterior  wall  of  the  uterine  fundus.  Increase  of  size  demands 
larger  arterial  blood-supply,  and,  consequently,  we  have  not  alone 
greater  habitual  venous  congestion,  but  the  periodical  determina- 
tion of  blood  at  the  menstrual  period  adds  to  the  general  uterine 
derangement.  Any  further  obstruction  to  the  free  flow  of  blood 
still  more  increases  the  evil.  The  vicious  circle  may  commence 
either  in  morbid  processes  promoting  congestion  and  weight  in 
the  uterine  wall,  or  in  an  interruption  to  the  circulation  at  the 
'  axis  of  suspension,'  with  consequent  alteration  of  tissue  at  this 
part.  These  conditions  may  be  secondary  to  pathological  extra- 
uterine states,  such  as  tumours,  adhesions,  inflammatoiy  eff'usions, 
a  retro-hsematocele,  pressure  from  the  rectum  posteriorly,  or  from 
the  abdominal  viscera  above.  Or  this  initiatory  mischief  may  be 
associated  with  ovarian  congestion,  inflammatory  efi'usion  in  the 
broad  ligaments,  contraction  and  thickening  of  the  Fallopian  tubes, 
and  occasional  perimetric  attacks. 

Symptoms. — The  symptoms  depend  to  a  great  extent  on  the 
degree  of  flexion,  the  size  of  the  body  of  the  uterus,  the  accompany- 
ing stenosis,  the  pressure  on  the  bladder,  or  such  complications  as 


240  DISEASES    OF   WOMEN. 

metritis,  endometritis,  and  perimetritis.  The  hypertrophied  fundus 
with  its  enlarged  vessels,  or  possibly  a  small  anterior  mural  fibroid, 
explains  the  menorrhagia  frequently  seen  in  these  cases.  Sterility 
being  a  common  consequence  of  anteflexion,  it  is  frequently  present, 
with  many  of  its  attendant  ills.  In  addition  to  the  dysmenorrhcea, 
there  is  occasionally  dyspareunia,  an  irritable  and  sensitive  vulvar 
orifice  and  vagina,  a  sensitive  and  congested  cervix,  with  pain  on 
pressure  in  the  posterior  fornix  of  the  vagina,  caused  by  a  swollen 
and  sensitive  ovary.  The  pressure  on  the  bladder  brings  frequent 
desire  to  pass  water,  with  difiiculty  of  retention ;  there  is  constantly 
a  sense  of  weight  and  pain  when  the  patient  stands  or  walks  for 
any  time,  and  neuralgic  pains  occur  in  various  parts. 

Diagnosis. — This,  with  the  exercise  of  any  care,  is  not  difiicult. 
A  digital  examination  detects  the  solid  body  of  the  uterus  lying 
anteriorly,  and  the  angle  of  flexion  marked  by  the  presence  of  a 
sulcus,  beneath  which  the  cervix  lies  in  the  axis  of  the  vagina,  if  it 
be  not  drawn  out  of  position  by  adhesions  or  cicatricial  contractions. 
Care  must  be  exercised,  if  the  flexed  cervix  he  draicn  anteriorly,  not 
to  mistake  the  displacement  for  a  partial  retroversion  or  retroflexion. 
The  uterus  occasionally,  in  anteflexion,  lies  low  in  the  vagina,  the 
process  of  descent  proceeding  at  the  same  time  as  the  forward  dis- 
placement. 

Having  so  far  detected  the  anteflexion,  it  is  well  to  make  a  careful 
examination  of  the  vaginal  roof,  search  the  anterior  and  posterior 
fornices  for  any  contracting  bands,  or  any  perimetritic  efiusions, 
while  we  ascertain  with  the  finger  the  degree  of  mobility  of  the 
uterus.  Still  retaining  the  finger  in  the  vagina,  we  make  a  careful 
bi-manual  abdomino-vaginal  examination,  determining  the  size  and 
mobility  of  the  fundus  uteri.  If  doubt  still  exist  as  to  whether  the 
tumour  be  an  intra-mural  fibroid,  or  some  efi'usion  which  may  have 
formed  in  front  of  the  uterus,  we  must  complete  the  examination 
with  the  uterine  sound.  This  we  may  find  some  difiiculty  in  pass- 
ing. It  may  have  to  be  withdrawn,  and  a  new  curve  given  it 
according  to  the  degree  of  flexion,  before  we  can  succeed.  When 
we  have  introduced  it,  we  can  satisfy  ourselves  of  the  exact  shape, 
direction,  sensitiveness,  and  degree  of  mobility  of  the  uterus,  and 
judge  of  the  space  between  the  finger  and  the  sound  by  feeling  the 
instrument  through  the  uterine  wall.  Should  we  experience  a  difii- 
culty in  passing  the  sound,  in  a  case  of  anteflexion,  we  may  assist 
the  introduction  of  it  by  pressing  up  the  fundus  with  a  finger  in  the 
vagina,  the  handle  being  carried  well  back  to  the  perineum.     If  we 


UTERINE  DISPLACEMENTS. 


•241 


succeed,  the  sound  is  brought  steadily,  but  neither  forcibly  nor 
suddenly,  forwards,  and  the  fundus  is  raised.  By  such  an  examina- 
tion as  this,  it  is  hardly  conceivable  that  we  can  mistake  the  case  of 
anteflexion  for  one  of  fibroid,  or  vice  versa,  and  overlook  etiusions, 
any  old  adhesions,  or  a  vesical  tumour  or  calculus. 

Our  conduct  of  the  ease  by  local  interference  will  dejjend  on — 
'  (a)  The  discomfort  caused  by  the  flexion ; 

(6)  The  extent  to  which  local  measures,  as  the  introduction  of 
the  sound,  occasional  reposition,  and  the  use  of  a  pessary, 
afibrd  relief. 

(f)  The  presence  of  such  complications  as  perimetritis,  endome- 
tritis, uterine  fibroids,  or  adhesions. 

Every  case  of  anteflexion  must  be  treated  on  its  individual  merits. 
AVhen  we  find  that  local  manipulation  is  ill  borne,  that  any  inflam- 
matory conditions  coexist,  and  that  we  fail,  after  reasonable  and 
judicious  efforts,  to  restore  the  uterus  to  its  proper  position,  it  is 
better  not  to  push  our  efforts,  but  rather  to  pay  careful  attention  to 
the.  bowels,  to  encourage  retention  of  urine  and  rest  in  the  dorsal 
decubitus,  to  apply  the  most  comfortable  vaginal  support,  and 
periodically  to  replace  the  uterus  with  the  finger.  Otherwise  the 
primary  indications  for  treatment  are  clear — -the  first,  to  try  to 
restore  the  uterus  to  its  normal  shape  and  position;  the  second,  to 
retain  it  by  mechanical  means  in  its  proper  place,  while  we  correct 
the  flexion  and  establish  the  patency  of  the  uterine  canal.     The 


Fig.  164. — Sdis'  Operatiox  for    Fig.  165. — Bilatekal  Division  of  the  Cek- 
CBEATiNG  New  Uteki>-e  Axis.  vrx:  with  Kuchenmeisteb's  Scissors. 


first  is  effected  by  the  uterine  sound,  aided  by  the  finger  in  the 
manner   already    described  ;    the    second    object    we    endeavour    to 

R 


242  DISEASES   OF   WOMEN. 

accomplish  by  a  suitable  pessary,  and,  if  necessary,  by  the  use  of  an 
intra-uterine  stem  to  straighten  the  canal.  The  general  principle  of 
relieving  local  congestion,  and  treating  any  inflammatory  conditions 
of  the  endometrium,  or  the  uterine  appendages,  before  we  trust  to 
a  mechanical  support,  is  to  be  observed.  In  short,  when  a  case  of 
painful  anteflexion  j)resents  itself,  our  duty  will  be  to  subdue  any 
local  inflammatory  state,  and  endeavour  to  replace  the  uterus.  If 
the  uterus  be  sensitive  and  congested,  a  few  scarifications  of  the 
cervix  will  in  all  probability  give  temporary  relief,  while  glycerine 
and  ichthyol  tampons  have  both  a  sedative  and  depletive  efiect.  The 
tampon  is  moistened  with  a  mixture  of  one  part  of  a  ten  per  cent, 
solution  of  ichthyol,  one  part  of  extract  of  hydrastis,  one  part  tinc- 
ture of  iodine,  and  three  parts  of  glycerine.  If  there  be  stenosis 
(with  dysmenorrhoea  and  sterility),  we  dilate  the  canal,  commencing 
with  a  small  bougie,  and  gradually  increasing.  Meantime  we  should, 
when  it  can  safely  be  done,  at  periodical  intervals  gently  I'etrovert 
the  uterus  with  the  sound,  replacing  the  pessary  while  the  uterus  is 
thus  retroverted.  The  step  that  frequently  gives  the  most  relief  is 
section  of  the  cervix  uteri. 

Sims'  Incision. — The  probe  point  of  Kuclienmeister's  scissors  should  be 
iiitrocliiced  for  about  three-quarters  of  an  inch,  and  the  cervix  divided  not 
quite  up  to  the  vaginal  reflexion.  We  noAv  incise  the  os  internum  with 
Sims'  knife,  already  described,  p.  145,  which  is  the  best  instrument  we  can 
use,  the  operator  having  it  directly  under  his  control. 

The  patient  is  placed  in  the  dorsal  position.  The  cervix  is  brought  well 
into  view,  and  is  held  securely  by  a  tenaculum.  The  blade  of  Kuchen- 
meister's  scissors  is  next  introduced  (the  canal  of  the  cervix  may,  if  neces- 
sary, be  dilated  previously),  and  the  posterior  cervical  wall  is  divided,  as  has 
been  just  described ;  Sims'  knife  is  now  taken  and  introduced  through  the 
internal  os,  and  the  posterior  cervical  wall  is  laid  open.  Every  precaution 
already  insisted  on  when  referring  to  division  of  the  cervix  for  malformations 


.  Fig.  166. — Dilatoii  for  stretching  Cervical  Canal  after  Incision. 
By  closing  the  handles  the  blades  expand. 

and  stenosis  has  to  be  taken.*   The  operation  should  be  performed  a  few  days 
after  a  menstrual  period.     We  must  insist  on  the  need  for  rest  and  care  until 

*  See  chapter  on  Minor  Gynsecological  Operations. 


UTERINE  DISPLACEMENTS.  243 

after  the  next  menstrual  epoch.     The  patient  should  be  kept  in  bed  for  some 
days.    There  is  a  certain,  though  slight,  percentage  of  risk  in  all  such  operations. 

The  operation,  however,  which  gives  most  satisfactory  results  is  that 
which  we  have  already  described,  and  consists  of :  (1)  bilateral  incision  of 
the  cervix,  reaching  nearly  to  the  vaginal  reflexion ;  (2)  crucial  incision  of 
the  stenosed  portion ;  (3)  free  dilatation  with  dilators  of  the  divided  canal ; 
(4)  closure  of  the  cervical  wounds  ;  lastly,  the  insertion  of  a  strip  of  sterilized 
iodoform  gauze  when  all  bleeding  has  ceased.  This  gauze  is  not  disturbed 
for  forty-eight  hours,  during  which  time  the  vagina  is  loosely  tamponed  witli 
some  sterilized  iodoform  and  ordinary  gauze.  Subsequently  the  dilatation  of 
the  canal  is  preserved  by  the  occasional  passage  of  an  ordinary  dilator. 

Plastic  Operations. — Professor  VuUiet  introduced  a  plastic  operation  for 
obstinate  stenosis  of  the  cervix.*  It  involved  a  rather  free  dissection  of  the 
anterior  vaginal  wall  at  its  attachment  to  the  cervix,  and  the  cutting  of  a 
large  uterine  flap  after  the  division  of  the  cervix.  It  is  an  operation  which 
is  tedious  and  can  seldom  be  called  for,  in  view  of  the  simple  and  equally 
efficacious  procedures. 

Dudley's  Operation. — With  the  view  of  obviating  the  tendency  to  closure  of 
the  cut  surfaces  after  division  of  the  uterus  for  anteflexion,  and  with  the 
further  object  of  straightening  the  canal,  Dudley  of  Chicago  has  devised  an 
operation,  which  George  Keith,  who  himself  practises  it,  thus  describes : — 

"  As  this  operation  may  have  to  be  performed  on  unmarried  women,  the 
smaller  end  of  the  smallest-sized  Sims'  speculum,  three-quai'ters  of  an  inch 
in  width,  must  be  the  one  selected  in  such 
cases.  It  is  thus  unnecessary  to  rupture  the 
hymen  unless  it  be  very  small.  The  vagina 
is  steiilized.  a  tenaculum  is  fixed  into  the 
centre  of  the  anterior  lip  of  the  cervix,  and 
the  uterus  is  drawn  slightly  downwards  to 
straighten  the  bend  as  far  as  possible.  A 
sound  is  passed  to  determine  the  exact  direc- 
tion of  the  canal,  which  is  then  thoroughly 
dilated.  This  is  followed  by  curetting,  a 
large  quantity  of  fungosities  being  usually  Fig.  167.^Dudley's  Opeka- 
removed.  The  operator  then  takes  the  tion.  Application-  of  Su- 
tenaculum  in  the  left  hand,  and  with  knee-  tuue;-.  (Keith.) 
bent  scissors  in  the  right  cuts  through  the 

whole  thickness  of  the  posterior  lip  of  the  cervix  almost  to  the  vaginal 
mucous  membrane.  There  are  now  two  cut  surfaces,  the  upper  or  right,  and 
the  lower  or  left,  and  each  requires  to  be  sutured  separately.  It  wiU  be  seen 
that  if  the  cut  surface  on  one  side  be  doubled  on  itself  so  that  the  point 
touches  the  base,  and  the  same  is  done  on  the  other  side,  the  point,  i.e.  the 
OS,  must  be  either  drawn  backwards  or  the  base  must  be  drawn  forwards. 
What  happens  is  that  the  os  is  drawn  backwards  at  the  vaginal  junction,  and 
fixed  in  this  position  by  sutures.  The  stitches  are  put  in  in  the  following 
way :  The  needle  is  passed  through  the  whole  thickness  of  the  point  on  one 
side  and  from  the  vaginal  surface  to  the  cerAncal,  and  in  the  reverse  direction 

*  Centralblait  fiii-  Gynahologie,  Jan.  20,  1394. 


244 


DISEASES   OF  WOMEN. 


through  the  whole  thickness  of  the  base.  The  stitch  is  then  tied,  thus  keep- 
ing the  cut  surface  doubled  on  itself.  A  similar  stitch  is  then  put  into  the 
lower  side,  one  stitch  on  each  side  being  usually  sufficient.  In  this  way 
the  incision,  which  was  originally  longitudinal,  has  become  transverse, 
although  in  two  halves. 

Intra-uterine  Stems. — I  have  said  little  of  intra-uterine  stems  in 
the  treatment  of  anteflexion,  for  two  sufficiently  good  reasons  : 
1st,  The  cases  are  very  rare  in  which,  with  judicious  management, 
they  are  required,  and  when  the  flexion  is  such  that  a  stem  is  indi- 
cated, it  will  be  found  in  practice  that  the  chances  are  about  equal 
between  success  and  failure  from  its  use.  2nd.  The  risks  incurred 
during  the  time  a  stem  is  worn,  and  the  constant  supervision  re- 
quired from  the  medical  attendant,  added  to  the  carelessness  of 
patients,  which  often  cannot  be  prevented,  render  the  use  of  an 
intra-uterine  stem  hazardous. 

/  never  employ  intra-uterine  stems  in  my  oivn  practice*  Should  the 
practitioner  use  a  stem  he  should  always  accompany  its  application  with  the 

strictest  injunctions  to  the  patient 
regarding  rest  and  medical  super- 
vision. The  precautions  to  be 
adopted  if  an  intra-uterine  stem 
be  used  in  anteflexion  are  these : 
(a)  Never  place  a  stem  in  the 
uterus  immediately  before  a  men- 
strual period;  and,  when  one  is 
worn,  remove  it  on  the  approach 
of  a  period,  (i)  Always  teach  the 
patient  how  to  remove  the  instru- 
ment by  means  of  a  string  attached 
to  the  lower  end  of  the  stem,  and 
direct  her  to  do  so  on  the  least 
indication  of  uneasiness,  the  occur- 
rence of  pain,  any  chilliness,  or 
feeling  of  general  malaise.  (c) 
Never  place  a  stem  in  the  uterus 
if  there  should  be  signs  of  past  or 
present  perimetritis,  or  during  an 
inflammatory  state  of  the  endome- 
trium. (cZ)  When  possible,  use  a 
smooth,  straight,  or  slightly  curved 
stem,  such  as  that  made  of  celluloid 


Fig.  168. — Supra-ptjbic  Suppobt. 
(Matthews  Bros.) 

Cousisting  of  two  lijjht  springs  and  front 

and  back   pads ;    the   front-supporting 

pad  or   pads   are   filled  with   air,  the 
,    quantity  of  which   is   regulated   by  a 

little  valve.     The  shape  of  the  springs 

and  general  arrangement  of  the  pads 

give  a  good  upward  and  backward  sup- 
port, with  a  very  soft  resilient  but  firm 

air  pressure.     The  support  is  very  light 

and  cool,  and  occupies  little  space,  and 

is  adjusted  in  a  very  few  moments.  ,       .  ,  .    ^-r 

or   vulcanite,     i^e)    Never  use   an 

intra-uterine  slem  with  external  perineal  strap  and  support.     (/)  The  stem 

should  not  reach  the  fundus  of  the  uterus. 

*  This  statement  must  be  qualified  by  the  exception  of  the  occasional  use  of 
my  celluloid  stem  after  operation  for  stenosis. 


These  diagmniiuatic  tigures  represent  (so  far  as  is  possible)  tlic  positiuns  (if 
tlie  pessaries  used  by  the  author  in  various  displacements.  They  also  show 
certain  pathological  complications  which,  when  present,  contra-indicato  the  use 
of  a  pessary,  and  which  are  not  discoverable  without  a  careful  examination, 
generally  under  antesthesia. 


1.  Large  retroflexed  uterus,  obliterating      2.  Anteflexed    uterus    with    elongated 


the  pouch  of  Douglas,  pressing  on 
the  rectum  and  drawing  the  fundus 
of  the  bladder  backwards.  A  typi- 
cal case  for  an  Alexander-Adams 
operation  or  ventro-suspension. 
(H.  M.-J.) 


cervix  pressing  on  the  bladder, 
drawing  on  the  rectum  and  alter- 
ing the  position  of  the  pouch  of 
Douglas ;  ovary  prolapsed  in  front 
in  utero-vesical  space.    (H.  M.-J.) 


3,  A.  Pouch  of  Douglas,  occupied  by  large  pyo-salpinx  adherent  to  the  uterus  or 
incorporated  with  it  and  altering  its  position ;  may  be  mistaken  for  reflexion, 
a  myoma,  an  ectopic  sac,  an  ovarian  cyst,  a  tumour  of  the  mesosalpinx,  or 
Fallopian  tube,  or  a  rectal  tumour. 
B.  Gives  an  idea  of  the  nature  of  the  tumour  examined  bimanually,  when  it  is 
likely  to  be  mistaken  for  a  myoma.     (H.  M.-J.) 

lTofucep.2U. 


4.  A. 


Large  uterus  enoroacliing  on  the  bladder,  which  is  elongated  as  the  result 
of  pressure  and  overdistension— Loaded  rectum  pressing  on  the  adnesa  in 
the  pouch  of  Douglas. 

Galabin's  pessary  supporting  the  uterus. 

Galabin's  pessary  supporting  the  uterus  with  myoma  in  anterior  wall. 

(H.  M.-J.) 


A.  Myoma  in  the  posterior  wall  of 

retroflexed  uterus — Ovary  and 
tube  in  the  pouch  of  Douglas. 

B.  Myomatous     anteflexed     uterus 

which  has  be  come  retroverted. 
(H.  M.-J.) 


ij.  A.  Complete  retroversion  with  pe- 
diculated  23olypus  growing  from 
fundus  occupying  the  pouch  of 
Douglas,  rectum  encroached 
upon  and  the  bladder  drawn 
upwards  and  backwards. 
B.  Same  uterus  with  fungoid  or  car- 
cinomatous mass  in  the  fundus. 
(H.  M.-J.) 


Myomatous  uterus  nucleus  in  an- 
terior wall  pressing  on  bladder — 
Pediculated  tumour  (a)  in  the 
pouch  of  Douglas — Myoma  or 
ovarian  solid  tumour.     (H.  M.-J.) 


8.  Fowler's  cradle  pessary  in  position. 
(H.  M.-J.) 


9.   Smith  -  Hodge      shaped     celluloid 
cushion  pessary  in  position. 

(H.  M.-J.) 


10.  A.  Glycerine     riug    in      position : 
uterus  has  been  replaced,  but 
not  in  normal  position. 
B.  Effect    on    same    uterus    of    an 
overdistended  bladder. 

(H.  M.-J.) 


11.  uterus  restored  to  the  normal  posi-         12.  Schultze's  figure-of-eight  pessary 
tion— S    pessary  applied  (curve  applied.* 

given  by  author).     (H.  M.-J.)  (H.  M.-J.) 


13.  Schultze's  sledge-shaped  pessary 
applied.* 

(H.  M.-J.) 


14.  Method  of  moulding  a  Schultze's 
ring  into  a  figure-of-eight  pessary. 
(H.  M.-J.) 


*  12,  13  and  14  are  after  Schultze. 


ITofacep.  245. 


CHAPTER   XII. 

UTERINE   DISPLACEMENTS  (continued). 

Retroversion  and  Retroflexion.* 

By  retroversion  we  understand  a  displacement  of  the  fundus  utein 
backwards,  so  that  it  lies  towards,  or  on,  the  rectum,  while  the 
cervix  uteri  is  directed  forwards  towards  the  pubes.  This  inclination 
occurs  in  varying  degrees,  from  a  slight  backward  version  to  an 
extreme  displacement,  in  which  the  os  uteri  is  thrown  upwards  and 
forwards,  and  the  body  of  the  womb  downwards  and  backwards. 
I  am  not  here  referring  to  the  retroversion  of  pregnancy. 

Schultze  puts  this  plainly  when  he  says,  '  Any  uterus  that  is  prevented 
from  taking  up  the  position  that  is  normal  to  it,  when  the  bladder  is  full  or 
empty,  must  be  looked  upon  as  displaced.'  And,  again,  '  that  any  uterus, 
the  axis  of  which,  even  -when  the  bladder  is  empty,  makes  with  and  behind 
the  axis  of  the  pelvic  inlet  a  stabile  angle  opening  outwards,  must  be  described 
as  retroverted.'  And  when,  with  this  diversion,  we  have  a  change  in  the 
form  of  the  uterus,  marked  by  a  curve  in  the  uterine  outline  with  the  con- 
cavity posteriorly,  the  state  is  regarded  as  a  backward  displacement  with 
retroflexion.  Retroversion,  however,  as  we  know,  may  occur  with  an  ante- 
flexion, as  anteversion  occurs  with  a  retroflexion.  Such  flexions  we  may 
regard  as  either  physiological  or  pathological.  The  former,  as  Schultze  well 
insists,  are  but  the  temporarj^  consequences  of  pressure  exerted  on  the 
normal  flexile  tissues  of  the  uterus ;  the  latter  are  permanent,  and  due  to 
inflammatory  processes,  or  congenital  and  infantile  conditions,  whether 
arising  intrinsically  in  the  tissues  of  the  uterus,  or  exerting  their  influence 
from  without,  through  abnormalities  in  the  uterine  supports,  or  inflammatory 
conditions  causing  adhesions,  contractions,  and  so  forth. 

"We  clearly  distinguish  between  the  terms  'retro-position'  or 
'  retro-deviation,'  and  '  retroversion  with  flexion,'  the  former  being 
such  altered  position,  with  possible  alteration  of  form  as  may  occur 
as  the  consequence  of  pressure  exerted  temporarily  on  certain  points 
in  the  axis  of  movement  of  the  uterus.  This,  then,  is  the  sole  con- 
dition that  we  are  considering,  and  in  doing  so  we  have  simply  to 
*  See  chap,  i.,  '  Anatomical  and  Clinical.' 


246  DISEASES   OF   WOMEN. 

keep  in  our  mind  a  movable  line  or  axis  lying  at  an  angle  to  the 
conjugate  diameters  of  the  inlet  and  cavity  of  the  pelvis,  determined 
by,  and  varying  according  to,  the  degree  of  distension  of  the  bladder 
in  front,  or  the  lower  portion  of  the  rectum  posteriorly,  influenced 
also  by  the  movements  of  respiration  and  pressure  from  above  of  the 
abdominal  muscles  and  the  intestines.  It  may  help  us  also  if  we 
imagine  the  uterus  as  a  lever,  the  longer  arm  of  which  is  above,  and 
the  fulcrum  at  the  utero-vesical  bond  of  connection.  Should  the 
bladder  be  empty,  the  plane  of  this  axis  will  lie  almost  horizontally 
between  the  coccyx  and  the  upper  border  of  the  pubes,  retreating 
upwards  in  proportion  as  the  bladder  is  distended,  until  it  passes 
behind  the  axis  of  the  inlet,  becoming  thus  retroposed,  and,  if  co- 
incidentally  pressure  from  behind  be  exerted  through  the  distended 
rectum  on  the  cervix,  this  retro-position  becomes  more  decided,  so 
that  the  axis  of  the  uterus  lies  somewhere  between  the  body  of  the 
second  sacral  vertebra  and  the  centre  of  the  outlet. 

We  remember  that  such  physiological  movements  occur  about  an 
axis,  determined  by  the  attachments  of  the  uterus,  situated  at  the 
junction  of  the  cervix  with  the  body  of  the  uterus.  Obviously  the 
resultant  of  any  forces  acting  above  or  below  this  axis,  whether 
anteriorly  or  posteriorly,  will  move  in  opposite  directions,  pressure 
on  the  cervix  behind  raising  the  fundus,  and  on  the  fundus 
posteriorly,  raising  the  cervix.  So  far,  this  is  physiological,  and 
given  a  normal  uterus  with  normal  attachments  and  play  of  move- 
ment, and  healthy  muscular  and  ligamentous  controlling  and 
supporting  structures,  the  womb  can,  and  does,  right  itself  from 
temporary  displacements  consequent  upon  the  varying  yet  natural 
conditions  under  which  it  is  placed,  in  the  inevitable  round  of 
functions  discharged  by  the  surrounding,  and  superimposed  organs. 

Schultze  himself  divides  the  anatomical  conditions  caxising  displacement 
of  the  fundus  backwards,  with  or  without  flexion,  under  five  heads  : — 

(a)  Puerile  uterus,  with  short  vagina,  or  senile  atrophy. 

(Jb)  Anterior  fixation  of  the  cervix. 

(c)  High  fixation  posteriorly  of  the  cervix,  with  shortening  of  one  of  the 
folds  of  Douglas. 

{d)  Shrinking  of  the  posterior,  or  lengthening  of  the  anterior,  uterine  wall. 

(e)  Relaxation  of  the  uterine  attachments,  this  including  more  especially 
the  folds  of  Douglas  and  the  round  ligaments. 

Causation. — Everything  that  tends  to  relax  the  uterine  supports, 
increase  the  size  and  weight  of  the  uterus,  weaken  the  uterine  wall, 
soften  and  congest  the  tissues,  diminish  the  natural  pelvic  supports 


UTEIIIXE   /i/Spf.ACEAfEXrS.  -n; 


of  the  uterus  inferiorly  and  posteriorly,  or  draw  the  uterus  back- 
ward by  adhesion,  may  be  included  under  the  heading  of  causation. 
We  thus  find  retroflexion  frequently  associated  with  pregnancy, 
laceration  of  the  cervix,  subinvolution,  uterine  fibroids,  metritis  and 
endometritis,  rectocele,  atonic  or  prolapsed  vaginal  wall,  ruptured 
perineum,  adhesions,  sedentary  and  standing  occupations,  neglect 
of  the  bladder.  It  is  met  with  oftener  in  married  women,  and 
those  who  have  borne  children,  than  in  the  nulliparous.  This  we 
might  anticipate  from  the  occurrence  of  chronic  hyperplasia,  and 
laceration  of  the  cervix  and  perineum,  as  frequent  consequences  of 
labour.  In  women  who  have  had  several  pregnancies  and  severe 
labours,  we  find  these  results  complicated  by  atonic  and  relaxed,  if 
not  prolapsing,  vaginal  walls.  These  likewise  predispose  to  retro- 
version. It  is  sometimes  encouraged,  if  not  produced,  by  unnecessary 
compression  of  the  abdomen  after  labour,  and  the  fashionable  corset 
is  not  to  be  overlooked  as  an  occasional  adjunct  in  the  causation  of 
reti'o-deviation. 

Tumours. — Other  causes  of  retroversion  are  tumours,  whether  of 
the  ovaries,  in  the  broad  ligaments,  or  of  the  bladder,  which  may 
push  the  uterus  backwards,  but  here  it  is  a  case  rather  of  retro- 
position  of  the  entire  uterus  than  true  retroversion,  which,  if  it  be 
present,  is  more  frequently  the  result  of  associated  adhesions  occur- 
ring posterior  to  the  uterus.  Differences  of  opinion  have,  and  do, 
exist  as  to  the  causal  relation  between  retroflexion  and  ovarian 
tumour.  Schultze's  view  is  rather  in  the  dii-ection  of  retroflexion 
favouring  the  growth  of  the  ovarian  tumour,  and  that  generally  a 
backward  displacement  has  existed  previous  to  the  occurrence  of 
the  ovarian  growth.  That  they  are  often  co-existent  conditions  is 
proved. 

I  have  spoken  of  simple  backward  displacement,  but  we  do  not 
forget  that  such  malposition  may,  as  has  been  pointed  out  by  Klob, 
Veit,  and  Schultze,  be  attended  by  a  iicisting  of  the  uterus  to  the 
right  or  left  side,  according  to  the  situation  of  the  source  of  con- 
traction, whether  in  the  broad  ligament  or  a  fold  of  Douglas  of 
either  side. 

Influence  on  the  Ovaries.— With  such  movements  of  the  uterus 
we  understand  how  the  position  of  the  ovaries  must  be  correspond- 
ingly altered.  Just  in  proportion  as  the  uterus  is  retroposed,  so 
there  is  the  tendency  for  the  ovaries  to  lie  out  of  their  normal 
position.  But,  as  Schultze  points  out,  provision  against  backward 
gravitation  of  the  ovary  is  made  by  the  relaxation  of  the  ligamentum 


248  DISEASES   OF   WOMEN. 

ovarii,  and  the  suspensory  ligament  of  the  ovary.  However,  as  we 
know  ulinically,  it  is  not  uncommon  to  tind,  in  cases  of  retroversion 
and  retroflexion,  either  one  or  both  ovaries  lying  in  the  pouch  of 
Douglas,  and  experience  proves  how  frequently  such  backward  pro- 
lapse of  an  ovary  accompanies  a  retroversion ;  further,  how  inflam- 
matory states  of  the  adnexa,  tubal  and  ovarian,  are  constantly  met 
with  as  complications.  These,  of  course,  are  usually  the  sequences  of 
metritic  and  perimetritic  inflammation,  and  have,  as  their  most  un- 
fortunate attendants,  adnexal  adhesions  and  peritoneal  contractions. 

Congenital  Anomalies  as  Causes.^ — Apart  from  all  such  acquired 
causes  of  this  condition,  there  are  those  congenital  forms  with  or 
without  other  anomalies,  either  in  the  uterus  itself,  such  as  elonga- 
tion of  the  cervix,  undue  proportion  in  the  length  of  the  anterior 
wall,  at  times  associated  with  vaginal  or  other  departures  from  the 
normal  in  the  genitalia.  Such  slight  congenital  flexions  rarely  in 
themselves  give  rise  to  more  serious  troubles  than  dysmenorrhoea 
and  sterility. 

We  must  also  bear  in  mind  that  pelvic  inflammations,  whether 
seriously  involving  the  adnexa  or  not,  leave  in  their  wake  plastic 
exudations  and  peritoneal  contractions.  Seeing  the  consequences 
during  and  after  convalescence  of  such  inflammatory  processes,  I 
think  we  may  admit  that  we  are  too  apt  to  rest  content  with  their 
immediate  control  and  the  recovery  of:  the  patient,  without  the 
needful  rectification  of  the  sequelse  of  the  attack.  "Warm  douchings, 
massage  of  rectum  and  vagina,  more  prolonged  rest,  avoiding  the 
dorsal  position,  the  use  of  a  suitable  soft  support,  and  the  administra- 
tion of  such  drugs  as  are  calculated  to  promote  absorption  of  the 
efi'used  products,  and,  finally,  cold  lavements,  are  some  of  the  means 
which  we  may  adopt.  It  is  in  such  cases,  when  complicated  with 
retroflexion,  that  the  treatment  associated  with  the  name  of  Schultze 
is  of  such  value.  Though  great  benefit  may  be  derived  from  a 
course  of  waters  or  baths  at  Wopdhall  Spa,  Kreuznach,  or  Salso- 
Maggiore,  in  the  absorption  of  pelvic  effusions,  adnexal  thickenings, 
and  enlargements  of  the  uterus,  it  is  not  prudent  to  buoy  up 
patients  with  too  strong  hopes  of  the  efifects  of  these  waters  and 
spas. 

Symptomatology. — With  such  an  etiological  and  pathological 
summary  before  us,  we  clinically  divide  backward  displacements 
into  those  in  which  the  uterus  is  reducible  and  movable,  with  or 
without  complications,  and  those  in  which  the  uterus  is  adherent 
and  irreducible,   and  where  adnexal  complications,  not  necessarily 


UTERINE   DISPLACEMENTS. 


249 


but  generally,  are  co-existent.  And  such  clinical  division,  if  it  be 
somewhat  general  and  wanting  in  accurate  differentiation  of  causes, 
lias  its  special  practical  value  in  its  bearing  on  treatment  in  regard 
to  those  cases  which  do,  and  those  which  do  not,  demand  operative 
interference. 

The  evidences  of  retroversion  are  pelvic  discomfort,  rectal  and 
bladder  pressure,  distress  in  standing  or  walking,  pain  in  the  back 
and  during  defalcation.  The  gravity  of  the  symptoms  arising  from 
retroversion  or  retroflexion  has  no  definite  relationship  to  the  extent 
or  severity  of  the  displacement.  We  find  the  symptoms  aggravated 
in  mild  cases,  and  at  times  almost  absent  in  those  in  which  we 
would  expect  to  find  considerable  distress.  Should  an  acute  retro- 
version  occur,    which    is    rare,    the    immediate    consequences    are 


Fig.  169. — Degrees  of  Eeteoversion. 
(schroedei;.) 


Fig.  170.^ — Eetroflexion. 
(From  Schroeder.) 


generally  very  severe.  Great  pain,  tendency  to  collapse,  and 
inability  to  stand,  are  amongst  the  most  prominent.  When  retro- 
version has  existed  for  some  time,  symptoms  arise  which  are  the 
secondary  consequences  of  the  pathological  changes  induced  by  the 
continued  pressure  on  the  rectum  and  Wadder :  dysmenorrhoea, 
menorrhagia,  sterility,  cystitis,  and  rectitis.  Should  conception 
occur  and  the  womb  be  retroverted,  or  should  it  be  displaced  during 
the  early  weeks  of  pregnancy,  it  is  not  unusual  for  the  patient  to 
abort  from  the  third  to  the  fourth  month,  when  the  uterus  enlarges 
and  the  irritation  and  distress  increase. 

Some  there  are  who  would  make  light  of  the  sufferings  and  the  conse- 
quences which  follow  in  the  wake  of  true  displacements.  This  is  not  my 
experience,  and  from  every  point  of  view  I  refuse  to  regard  a  woman  as 


250  DISEASES   OF   WOMEN. 

healthy  who  has  a  retroverted  uterus.  Psychologists  have  proved,  side  by 
side  with  gyntecologists,  the  correlation  there  exists  between  displacements 
and  certain  mental  states,  which  have  completetely  disappeared  with  rectifi- 
cation of  the  error  of  position,  and  alienists  now  universally  acknowledge  the 
practical  importance  of  its  treatment  in  the  insane. 

Diagnosis. — By  a  digital  examination  we  detect  the  cervix  uteri 
directed  towards  the  symphysis  pubis,  and  the  fundus  resting  on 
the  rectum.  These  signs  at  once  indicate  retroversion.  In  the 
diagnosis  of  adnexal  complications  and  adhesions  anaesthesia  is  a 
most  valuable  aid  in  doubtful  cases.  The  extent  of  the  fundal 
tumour,  felt  posteriorly,  affords  a  rough  measure  of  the  degree  of 
displacement.  The  combined  method  of  examination,  and  the  use 
of  the  uterine  sound,  will  clear  up  any  doubt.  Before  we  pass  the 
sound,  we  must  remember  that  pregnancy  and  retroversion  are  not 
uncommonly  co-existent.  It  is  not  to  he  employed  until  we  can  satisfy 
ourselves  that  the  looman  is  not  pregnant.  We  have  to  beware  of  the 
error  of  mistaking  a  fibroid  tumour  in  the  posterior  wall  of  the 
uterus,  a  hsematocele,  an  effusion  (either  cellular  or  intra-peritoneal) 
for  the  retroverted  or  retroflexed  uterus.  The  history  of  the  case, 
the  conjoined  examination,  the  uterine  sound,  and  reposition  of  the 
uterus,  should  prevent  this  error.  Concretions  in  the  rectum,  peri- 
metric effusions,  and  more  frequently  interstitial  fibroids,  are  often 
mistaken  for  retroversion. 

Prophylaxis. — In  dealing  with  the  prophylaxis  of  backward  dis- 
placement, any  reference  to  anticipatory  and  preventive  measures 
must  necessarily  be  a  very  condensed  and  concise  one.  We  will 
take  them  somewhat  in  the  order  in  which  I  have  referred  to  the 
causes  of  the  condition.  First  in  importance  is  attention  to  disten- 
tion and  over-distention  of  the  bladder.  Women,  for  various  and 
obvious  reasons,  are  apt  to  neglect  such  distention,  and  to  habituate 
themselves  to  its  occurrence,  resisting  the  natural  demand  for  relief 
more  than  men. 

The  most  important  caution  that  can  be  given  to  a  woman  who 
has  to  wear  a  support  is  to  empty  the  hlaclcler  at  regular  intervals.  It 
were  well  that  a  like  caution  were  given  to  all  women  after  a  recent 
labour.  Certainly  it  may  be  asserted,  considering  the  great  import- 
ance of  the  matter,  that  women  generally  are  not  made  sufficiently 
alive  to  the  dangerous  consequences  which  follow  over-distention. 
Constipation  and  costive  hoivels  are  only  of  secondary  importance  to 
the  bladder.  To  prevent  rectal  overloading,  to  maintain  the  tone 
of   the    sphincters,    to   cure   hfemorrhoidal    conditions,  to   prevent 


rTERINE   DISPLACEMENTS.  251 


straining  in  defalcation,  are  here  our  principal  indications.  I  do 
not  spejik  of  affections  of  either  bowel  or  bladder  that  may  demand 
special  interference  for  their  cure. 

Attention  to  the  uterus  after  labour,  especially  during  the  first  and 
second  months,  has  certainly  not  been  given  as  it  ought  to  have 
been.  Considering  that  by  far  the  largest  proportion  of  cases  of 
backward  displacement  are  due  to  post-partum  effects,  this  must  be 
acknowledged. 

Flaischlen,*  of  Berlin,  insists  on  the  importance  of  treatment  after  child- 
bed, and  that  if  there  be,  notwithstanding  reposition,  recm-rent  retroflexion, 
a  pessary  should  be  worn  for  six  months.t  Nicholson,^  of  Pennsylvania,  in 
a  recent  article,  quotes  Rissman  upon  the  cure  and  prevention  of  displace- 
ments in  the  puerperium.  Rissman  cites  Ahlfekls  and  Fritsch,  that  we 
should  ascertain  the  position  of  the  uterus  at  the  end  of  the  first  week,  and, 
if  it  be  required,  that  a  pessary  should  be  inserted,  and  he  instances  cases  in 
which  cure  of  the  retroposition  followed  this  treatment,  while  the  patients 
were  kept  as  much  as  possible  on  the  side.  Many  other  authorities  are  in 
favour  of  the  introduction  of  a  support  at  the  end  of  a  third  week,  and  Riss- 
man lays  special  stress  on  the  lateral  position  with  the  occasional  assumption 
of  the  prone  position. 

"Whatever  view  we  maj^  hold  with  regard  to  these  suggestions,  I  think  it  is 
undoubted  that  the  time  has  arrived  for  the  recognition  of  the  great  import- 
ance of  attention  to  the  position  of  the  uterus  during  the  puerperal  month, 
attention  to  the  involution  of  the  uterus  by  means  taken  to  secure  it,  and 
thorough  rectification  of  any  perineal  deficiencies.  '  Indeed,'  says  Flaischlen, 
'  the  chief  contingent  of  all  mobile  retroflexions  are  those  puerperal  ones 
which  are  not  submitted  to  medical  advice  for  months,  or  even  years,  after 
their  origin.'  I  cannot  enter  into  the  consequences  of  retroversion  on  the 
gravid  uterus,  its  efi'ects  in  abortion  and  incarceration.  When  detected, 
early  reposition  and  the  use  of  a  pessary  is  the  obvious  course  to  pursue. 
Doubtless  auto-reposition,  with  the  ad^^ance  of  pregnancy,  does  happen,  but 
it  is  not  well  to  rely  on  it,  and  reposition  under  narcosis,  properly  conducted, 
should  be  carried  out  (see  p.  70). 

Treatment  of  Retrodisplaeements.^ — We  now  approach  the  actual 
treatment  of  a  retroverted  or  retroflexed  uterus  which  is  movable 
and  reducible.  In  all  efforts  to  effect  reposition,  it  is  best  to  place 
the  patient  in  the  semi-prone  position.  If  there  be  still  difficulty, 
the  woman  should  be  put  in  the  knee-pectoral  position,  her  chest 
being  brought  well  down  on  the  couch,  and  advantage  taken,  at  the 
moment  of  reposition,  of  a  strong  expiratory  effort  on  the  part  of 

*  Zeit.  f.  Gehurt.  und  Gyrnvk. 

t  Rissman,  Munch.  Med.  Wochen.,  March  G,  1900. 

+  Paper  by  W.  R.  Nicholson,  M.D.,  'Digest  of  Recent  Literature,  wifh  a 
special  reference  to  Uterine  Displacements.'  Univ.  Med.  Magazine,  Pennsyl- 
vania, Feb.,  1901. 


252 


DISEASES   OF   WOMEN. 


the  patient.  In  some  cases  counter-pressure  may  be  made  in  the 
dorsal  position,  between  the  hand  on  the  abdomen,  pressing  down 
the  cervix,  and  the  fingers  of  the  other  hand,  in  the  vagina,  which 
elevate  the  fundus.  In  all  these  manipulations  the  bladder  and  rectum 
should  he  empty.  Sometimes  the  retroverted  uterus  is  congested, 
tender,  and  sensitive.  In  such  a  case  it  may  be  well  to  combine 
periodical  reposition  by  the  fingers,  or  an  extra-uterine  repositor, 
with  occasional  depletion,  the  use  of  the  hot  douche,  and  the  intro- 
duction of  a  glycerine  plug  at 
night,  before  we  permanently 
replace  the  uterus  and  apply  a 
pessary.  But  this  necessity  is 
rare,  and,  when  it  is  practicable 
to  do  so  without  much  force, 
the  uterus  should  be  restored 
to  its  normal  position,  and  a 
pessary  be  adapted  to  the  size 
of  the  vagina  and  the  cervical 
development  of  the  uterus. 

The  best  repositor  is  the  finger, 
and  if  it  fail,  the  uterine  sound. 
This,  used  with  delicacy  and 
caution,  is  the  safest,  most 
efi'ectual,  and  the  simplest  intra- 
uterine instrument  for  sur- 
geons. To  replace  the  uterus, 
we  use  the  semi-prone  or  knee- 
elbow  position  ;  *  carrying  the 
index  and  middle  fingers  of  the 
left  hand  into  the  vagina,  and 
resting  these  against  the  uterus,  we  press  the  fundus  steadily  for- 
wards. Should  this  not  rectify  the  displacement,  we  may  place  the 
index  and  middle  fingers  of  the  right  hand  against  the  .  cervix 
anteriorly,  and  press  it  backwards  towards  the  sacrum.  At  the 
same  time  pressure  is  made  on  the  fundus  by  a  finger  in  the  rectum. 
We  often  thus  succeed  in  reducing  by  the  fingers  a  retroverted 
uterus.  This  plan  should  be  tried  before  we  use  the  sound  as  a 
repositor. 

We  can  exert  greater  power  with  the  fingers  introduced  into  the 
rectum,  directing  the  pressure  against  the  fundus,  while  the  woman 

*  Pae:e  254. 


Fig.  171. — Introduction  of  Sound  be- 
fore KoTATioN.    (Hart  and  Barbour.) 


UTERINE  DISPLACEMENTS. 


253 


is  in  the  knee-elbow  posture.     I  have  never  seen  harm  accrue  from 
judicious   attempts  to  replace   the   uterus  with   the   sound.     The 
author's  extra-uterine 
repositor,  or  elevator,  j 

will  be  found  a  use- 
ful instrument,  more 
especially  when  preg- 
nancy complicates 
the  retroversion  (Fig. 
56).* 

Having  introduced 
the  sound,  the  rougliened 
face  of  the  handle  being 
directed  backwards,  the 
operator  takes  it  lightly 
in  the  left  hand,  and 
carries  it,  with  a  gentle 
sweep,  upwards  and  for- 
wards to  the  right,  while 
the  handle  is  made  to 
describe  a  semicircle, 
and  the  intra  -  uterine 
portion  of  the  sound  is 
thus  gently  rotated; 
finally  the  handle  is 
carried  w^ell  back  to  the 
perineum.  That  the 
uterus  may.  through  the 
presence  of  adhesions, 
resist  all  attempts  at 
reposition,  is  not  to  be 
forgotten.  To  an  experienced  hand  the  degi-ee  of  resistance,  both  to  finger 
and  sound,  indicative  of  such  an  impediment  is  readily  discernible,  but  this  is 
not  so  in  the  case  of  the  inexperienced,  and  therefore  aU  the  more  care  must 
be  exercised  by  beginners  in  using  the  sound  for  the  purpose  of  replacement. 

When  the  os  uteri  is  directed  far  forwards  we  may  not  be  able  to  introduce 
the  sound  in  this  manner.  The  handle  may  have  to  be  directed  anteriorly 
under  the  pubes,  and,  when  introduced,  the  fundus  must  be  first  partially 
raised  by  pressing  on  the  centre  of  the  sound  with  the  finger  of  the  right 
hand,  before  the  rotatory  sweep  is  made  with  the  left.  The  sound  is  not  to 
he  introduced  and  simply  rotated  on  its  axis. 

Should  a  flexion  complicate  the  displacement,  the  sound  must  be 
curved  according  to  the  degree  of  flexion.     We  may  not  be  able  to 

*  See  pages  70-73  for  description  of  the  repositor,  and  directions  for  the  use 

of  the  uterine  sound. 


Fig.  172. — Kotation  of  Sound  ix  Kktuovehsiox — 
sheawng  the  sweep  given  to  the  handle. 
(Adapted  fkom  Hakt  and  Bai;bock.) 


254  DISEASES    OF   WOMEN. 

straighten  the  uterus.  The  same  caution  must  be  exercised,  and 
the  same  means  adopted,  as  in  the  case  o£  anteflexion.  Any  previous 
inflammatory  condition  has  to  be  controlled.  The  uterus  may  be 
partially  straightened  by  the  uterine  sound,  or  still  more  so  by 
conjoined  recto-vaginal  manipulation,  the  index  and  middle  fingers 
of  the  right  hand  in  the  vagina  pressing  the  cervix  downwards  and 
backwards,  while  the  same  fingers  of  the  left  in  the  rectum  press 
the  fundus  steadily  upwards  and  forwards.  The  manoeuvre  is  bes  t 
effected  in  the  knee-elbow  position.  The  sound  requires,  in  its  use, 
gentleness  and  patience.  The  ill  effects  attributed  to  it  are  generally 
the  consequences  of  ill-advised  and  unjustifiable  force,  or  of  its 
introduction  at  imjoroper  times. 

In  the  treatment  of  retroversion,  judicious  and  patient  manipulation 
of  the  uterus  by  the  postural  method,  careful  reposition  by  means  of 
the  sound,  and  contemporaneous  adjustment  of  a  suitable  pessary  will 
in  the  majority  of  cases  obviate  the  need  for  operative  interference. 

When  we  have  succeeded  in  replacing  the  womb,  our  next  object 
is  to  retain  it  in  its  normal  position,  and  a  pessary  of  the  proper  size 
is  selected  and  introduced.  This  should  be  worn  constantly  for 
some  time.  I  have  had  more  pet'manent  satisfactory  results  with 
Fowler's  pessary  than  with  any  other.  This  statement  refers  to  cases 
in  which  we  find  that  the  Hodge  or  ring  is  not  sufficient  to  support 
the  fundus.  After  a  few  months  it  can  be  replaced  by  a  suitable 
lever  Hodge,  with  or  without  a  pad,  or  possibly  a  glycerine  ring.* 

There  can  be  no  doubt  that  the  pessary  which  is  capable  of  adapta- 
tion to  most  cases  of  retroversion  is  the  lever-pessary  of  Hodge. 

'  As  its  name  indicates,'  says  Goodell,  'this  pessary  acts  on  the  principle 
of  a  lever;  but  the  mechanism  of  its  action  is  twofold.  By  stretching  the 
vagina  upward  and  backward,  it  draws  the  cervix  in  the  same  direction. 
The  womb  then  turns  on  its  central  point  of  ligamentous  attachment  as  on  a 
fixed  pivot,  and  the  fundus  is  consequently  tilted  forwards.  The  womb 
itself  thus  becomes  a  lever,  of  which  its  point  of  attachment  to  the  bladder  is 
the  fulcrum.     The  power  is  applied  to  the  cervix,  and  the  fundus  becomes 

*  Larger  sizes  of  Fowler's  cradle  pessary  than  those  usually  sold  are  made  by 
Arnold.  They  are  required  in  old-standing  cases  of  retroversion  with  vaginal 
prolapse.  In  all  cases  in  which  there  is  tenderness  and  sensitiveness,  it  is  well 
to  prepare  the  patient  by  the  application,  three  times  in  a  week,  of  an  antiseptic 
tampon  of  salicylic  or  boric  acid  wool  soaked  in  glycerine,  which  is  pressed  up 
into  the  posterior  fornix  of  the  vagina,  so  as  to  jjush  forwards  the  fundus ;  while 
by  a  second  tampon,  applied  below  and  in  front  of  the  cervix,  this  latter  is  pushed 
back ;  the  superior  plug  is  thus  assisted  in  its  action  on  the  fundus.  Both  plugs 
are  finally  retained  in  position  by  a  roll  of  antiseptic  wool  passed  into  the  vagina. 
In  a  large  number  of  cases,  however,  the  pessary  should  be  moulded  at  the  time 
from  tire  celluloid  ring,  to  the  shape  most  suitable. 


UTEBINE  DISPLACEMENTS.  255 

the  weight,  or  resistance.  This  action  remedies  retroversion,  but  not 
retroflexion,  unless  conipHcatod  with  retroversion,  as  it  usually  is.  The 
anterior  vaginal  wall,  with  the  visceral  pressure  above  it,  now  becomes  the 
power  applied  to  the  lower  limb,  or  "'  long  arm,"  of  the  lever ;  t^ie  posterior 
vaginal  wall  is  the  fulcrum,  or  support ;  and  the  upper  limb,  or  short  arm, 
lying  behind  the  cemx,  directly  pushes  the  Aveight  or  fundus  uteri.  This 
action  tends  to  remedy  both  retroflexion  and  retroversion.  For  instance, 
during  the  act  of  inspiration  the  descending  diaphragm  crowds  down  the 
abdominal  viscera  upon  the  bladder,  to  which  are  attached  the  cervix  uteri 
and  the  anterior  wall  of  the  vagina.  These  organs,  therefore,  descend.  As  a 
result,  the  lower  or  fore  end  of  the  lever  is  necessarily  pushed  down  by  the 
descending  anterior  wall  of  the  vagina,  on  which  it  rests,  while  its  upper  or 
hind  end  proportionately  rises  up  and  tilts  forward  the  retroverted  or  the 
retroflexed  fundus.  In  expiration,  the  reverse  takes  place.  The  pressure  is, 
therefore,  not  a  steady,  but  a  gentle  rocking  one,  which  is  the  most  efficient 
of  all.  This,  also,  is  one  least  liable  to  inflict  injury  on  the  soft  parts,  because 
the  points  of  pressure  are  var^'ing  ones.  But  to  attain  these  ends  the  pessary 
must  be  mobile,  and  never  so  lomj  as  to  ^mt  the  vagina  o)i  the  stretch  ;  other- 
wise it  loses  its  distinctive  character  of  a  lever,  and  degenerates  into  an  ordinary 
ring  pessary.  It  should  further  impinge  on  the  soft  parts  only,  and  tahe  no 
hearings  on  the  solid  structure  of  the  pelvis.  .  .  .' 

The  Smith-Hodge  pessary,  with  the  cushion  full  of  glycerine,  and 
of  the  shape  shown  iu  Fig.  174,  is  a  useful  pessary  in  those  cases 


Fk;.  17o.— Thi.mas's  MuDiiaiiD  Fig.  174.— Akxold's  GLTCEiaxJi 

Smith-Hodge.  Pad. 

To  be  had  in  celluloid. 

in  which  there  is  a  sensitive  fundus  or  ovary.  Similar  pessaries  are 
made  with  the  cushion  filled  with  air.  These  pessaries  are  not 
durable.     They  are,  moreover,  apt  to  lose  their  shape. 

To  introduce  Hodge's  pessary,  bring  the  woman,  on  her  back,  or 
in  the  semi-prone  position,  over  the  edge  of  the  couch  or  bed,  with 
the  knees  well  drawn  up.  The  pessary  is  now  taken  in  the  right 
hand,  while  the  labia  are  held  lightly  apart  with  the  fingers  of  the 
left,  at  the  same  time  that  the  perineum  is  pressed  in  a  downward 
direction.  The  pessary,  with  its  uterine  or  longer  end  in  a  line 
with  the  vulvar  orifice,  is  now  passed  into  the  vagina,  the  principal 
pressure  being  directed  on  the   perineum ;  when  the   support  has 


256 


DISEASES   OF   WOMEN. 


completely,  passed  the  vulva,  the  fingers  of  the  right,  or  conducting 
hand,  are  changed  so  as  to  turn  the  pessary  half  round  on  its  long 
axis,  thus  bringing  the  concavity  of  the  large  curve  to  point  for 


Fig.  175. — First  Step  of 
Introduction. 


Fig.  176. — Second  Step  of 
Introduction. 


wards  to  the  interior  vaginal  wall.  This  is  the  moment  of  greatest 
pain  to  the  woman,  and  any  bungling  in  rectifying  the  position  of 
the  pessaiy,  as  it  lies  pressing  on  the  front  of  the  cervix,  causes 

still  greater  discomfort.  The 
index-finger  of  the  right 
hand  is  therefore  quickly 
transferred  to  the  upper 
bar,  which  iS;  hooked  or 
pressed  down,  so  as  to  glide 
over  the  cervix  into  the 
vaginal  cul-de-sac  behind. 
The  relation  of  the  pessary 
to  the  cervix  is  ascertained, 
the  degree  of  tension  of  the 
vaginal  roof  felt,  and  the 
exact  position  of  the  uterus 
determined,  before  we  per- 
mit the  patient  to  rise.  The 
lower  bar  presses  on  the  soft 
and  yielding  anterior  wall  of  the  vagina,  instead  of  on  the  pubic 
bones.  It  is  well  always  to  explain  to  the  patient,  or  friend,  the 
exact  position  of  the  pessary  in  the  passage.     If  uneasiness  should 


Fig.  177. 


-Smith-Hodge  Pessary  in 
Position. 


I ' TK I! rXK    DISPLACEMENTS. 


2o7 


follow,  we  should  instruct  her  how  to  remove  it,  by  pulling,  not 
too  forcibly,  on  the  lower  bar,  and  by  turning  the  instrument  on 
its  long  axis  and  gently  withdrawing  it.  If  a  case  of  retroversion 
should  resist  the  application  of  a  pessary,  the  one  lesson  every 
prudent  practitioner  has  to  learn  is  patience.  By  the  daily  practice 
of  the  knee-elbow  posture,  local  measures  directed  to  reduce  con- 
gestion and  inflammation,  by  habitual  reposition,  and  the  education 
of  the  vagina  and  uterus  to  the  presence  of  a  well-fitting  pessary, 
we  ultimately  conquer. 

I  cannot  speak  too  strongly  of  the  advantages  of  keeping  ready  at  hand 
several  sizes  of  these  rings  of  Schultze's,  or  tliose  made  for  me  by  Messrs. 


Fir,.  178.— A  C!ellul()id   Ring    Fig.  179. — Same  finally  mouldeo 
WITH  WiUE  Inside.  for  a  Case  of  Eetroveksion,  show- 

ing THE  POSTEEIOR  ARM  CURVED  TO 
SfPPORT   THE   UTERUS. 


Fig.  180.— First  Shape. 


Fig.  181. — Second  Shape. 


Arnold.     Having  carefully  examined  the  vaginal  roof,  and  noted  tlie  size 

required,  a  few  rings  are  taken  and  thrown  into  a  basin  of  very  hot  water  ; 

when  they  are  pliable,  one  is  given  the  shape 

shown  in  Fig.  180.     The  ring  is  again  thrown 

back  into  the  water  for  a  few  seconds,  and  on 

being  withdrawn  it  is  given  the  form  shown  in 

Fig.  181. 

It  is  again  immersed,  and  after  removal  the 
second   curve   is  made  (Fig.  182).      After  a 
few  seconds'  final  immersion,  the  pessary  may 
be  made  to  assume  the  exact  shape  desired,  and  the   arms   of  tlie   lever 
brought  to  the  proper  length  and  angle  required  (Fig,  179  shape  advised). 

s 


Fig.  182.— Third  Shape. 


258  DISEASES   OF   WOMEN. 

The  pessaiy  is  next  thrown  into  cold  water,  and  left  in  it  for  a  few  minutes 
to  set.     The  red  celluloid  rings  are  not  so  liable  to  crack  in  moulding,  and 

they  keep  better  than  the  transparent  kind. 


Fig.  183. — Celluloid  Cushion  Pessary. 

This  is  a  perfect   pessary,  light,  durable,  and  aseptic.     It  was  made   at  my 
desire  by  Messrs.  Arnold. 


Massage  and  Manipulation. 

Schultze  practises  careful  stretching,  in  the  lithotomy  position,  of  iall  adhe- 
sions which  keep  the  uterus  in  its  false  position.  This  is  done  under  an 
antesthetic,  the  rectum  and  bladder  having  been  thoroughly  emptied.  The 
rectum  is  irrigated  with  warm  water.  The  index  and  middle  finger  of  the 
left  hand  are  passed  into  the  rectum,  and  the  thumb  of  the  same  hand  into 
the  vagina.  The  other  hand  is  placed  on  the  abdominal  wall.  Having 
determined  the  situation  and  nature  of  the  adhesions,  these  are  gi'adually 
stretched  without  any  tearing,  at  the  same  time  that  the  uterus  is  raised.  I 
have  learned  from  experience  that  much  can  be  done  by  manipulation  to 
free  recent  adhesions.  It  has  been  my  practice  in  cases  in  which  I  found 
these  interfered  with  reposition,  to  place  the  woman  in  the  knee-elbow 
posture,  and  both  by  rectum  and  vagina  to  manipulate  the  uterus  for  some 
days  before  trying  reposition  with  the  uterine  soimd.* 


Retroflexion. 

In  retroflexion  the  fundus  is  bent  backwards  on  the  cervix,  and 
lies  against  the  rectum.  Eetroflexion  maybe  a  congenital  affection, 
due  to  arrest  of  development  of  the  posterior  uterine  wall,  and  may 
remain  undetected  even  after  puberty.  In  practice,  however,  we 
have  nearly  always  to  treat  that  displacement  which  is  secondary 
or  acquired. 

Causation. — We  may  refer  to  the  causes  of  retroversion  when  we 
inquire  into  those  which  are  productive  of  retroflexion.  It  is  not 
diflicult  to  understand  how  the  uterus,  still  softened  and  enlarged 

*  See  Fig.  200,  Schultze's  figiu-e-of-8  pessary. 


UrKlUXK    DJ.^I'LA  (  EM  EN  7W.  -JS!) 


after  pregnancy,  with  strained  and  relaxed  ligaments,  or  with  the 
perineal  support  injured  and  weakened,  may,  while  in  a  state  of 
subinvolution,  yield  to  abdominal  or  pelvic  pressure,  and  bend 
at  the  axis  of  suspension.  In  those  cases  in  which  there  is  an 
enlargement  in  the  posterior  wall,  either  as  the  consequence  of  con- 
gestion or  hypertrophy,  or  an  intramural  fibroid,  we  can  readily 
understand  the  occurrence  of  retroflexion.  The  flexion  is,  as  a 
rule,  preceded  or  attended  by  version.  Contraction  of  the  uterine 
canal  leads  to  stenosis  and  obsti'uction  of  the  menstrual  flow,  while 
the  consequent  congestion  of  the  uterine  tissues  in  the  fundus,  and 
the  increase  of  weight,  still  further  encourage  the  tendency  to 
uterine  prolapse  and  flexion.  As  in  anteflexion,  cause  and  effect 
react  on  each  other  ;  the  longer  the  displacement  lasts,  the  larger 
the  uterine  fundus  becomes,  and  the  more  acute  the  angle  of 
flexion. 

Diagnosis. — In  examining  the  retroflexed  uterus  with  the  finger, 
the  OS  uteri,  occupying  almost  the  vaginal  axis,  is  at  once  reached, 
while  the  fundus  is  found  as  a  solid  mass,  filling  the  posterior  cul- 
de-sac,  a  well-defined  sulcus  separating  the  cervix  from  the  fundus. 
The  flexion  is  distinctly  traceable  with  the  finger.  We  confirm  the 
diagnosis  by  both  recto-vaginal  and  utero-vaginal  examination. 
Carrying  the  index-finger  of  the  left  hand  into  the  rectum,  we  feel 
the  fundus  through  the  rectal  wall,  and  encroaching  on  it  ;  with  the 
finger  of  the  right  hand  on  the  cervix,  we  can  draw  on  the  uterus, 
and  so  detect  the  mobility  of  the  tumour  and  the  conjoined  move- 
ment of  the  cervix  and  fundus.  It  is  only  in  those  comparatively 
rare  cases  where  the  uterus  is  enlarged  and  fixed  by  adhesions  or 
recent  effusions,  that  any  doubt  can  exist  after  a  careful  vaginal  and 
bimanual  examination.  To  confirm  our  diagnosis,  we  pass  the 
uterine  sound,  but  in  doing  this  we  must  exercise  even  greater 
caution  than  in  simple  retroversion.  The  difficulty  will  depend  in 
a  great  measure  on  the  degree  of  flexion.  The  sound  must  be  well 
curved,  corresponding  to  the  curve  of  the  uterine  axis ;  the  handle 
is  taken  lightly  in  the  right  hand,  with  the  concavity  of  the  instru- 
ment directed  forwards.  Guided  by  the  finger  of  the  left  hand,  the 
knob  is  introduced  as  far  as  the  internal  os ;  by  a  tour  cle  maitre  the 
direction  of  the  sound  is  reversed,  the  concavity  being  directed 
backwards,  and  the  handle  carried  well  forward  towards  the  pubes. 
Assistance  can  at  the  same  time  be  given  by  raising  the  fundus 
with  the  finger  of  the  left  hand  in  the  vagina.  In  those  cases  in 
which  the  os  is  directed  far  forwards  and  is  high  in  the  pelvis,  the 


200 


DISEASES  OF   WOMEN. 


I 


sound  must  be  introduced  with  the  concavity  turned  towards  the 
sacrum. 

Treatment. — All  that  has  been  said  in  regard  to  the  management 
of  retroversion  applies  with  equal  force  to  retroflexion.  A  suitable 
pessary  has  to  be  inserted  when  the  uterus 
is  replaced  and  the  curve  rectified.  In  the 
retroflexed  womb,  however,  there  is  the 
flexion  in  addition  to  be  corrected.  The 
sound  may  have  to  be  periodically  passed. 
If  an  intra-uterine  stem  be  employed,  we 
have  to  bear  in  mind  all  the  precautions 
(p.  244)  to  be  taken  both  before  introducing 
the  stem  and  during  the  time  it  is  worn. 
Schrceder  advises  it  to  be  placed  for  the 
first  few  days  in  the  retroverted  uterus, 
and  replacement  not  to  be  attempted 
until  it  has  been  thus  worn  for  a  little 
time. 

When  we  have  replaced  the  uterus,  we 
must  endeavour  to  retain  it  in  position  by 
one  of  the  forms^  of  pessary  recommended 
for  retroversion — more  especially  Fowler's 
cradle  pessary,  or  a  Hodge  suitably  moulded.  The  question  naturally 
arises.  What  is  to  be  done  to  relieve  the  patient  in  those  unfortu- 
nate cases  in  which  rectification  of  the  displacement  is  impossible, 
and  the  retroflexion  incurable? 

These  are  the  points  which  are  of  the  greatest  importance 
for  practitioners  to  remember  in  regard  to  backward  displace- 
ments. 

1.  In  maJcing  a  diagnosis,  should  there  be  any  cause  for  doubt, 
have  the  rectum  and  bladder  emptied,  and  examine  the  patient 
bi-manually,  with  two  fingers  in  the  rectum,  by  the  recto- 
abdominal,  as  well  as  by  the  vaginal  method.  The  semi-prone 
position  and  that  of  the  knee-elbow  should  also  be  availed  of, 
as  both  throw  valuable  light  on  the  relation  of  the  ovaries  to 
the  uterus,  as  well  as  on  the  mobility  and  size  of  the  uterus  and 
adnexa. 

2.  Ansesthesia  is  essential  for  a  correct  diagnosis  in  certain  cases. 
In  conducting  examinations  imder  ancesthesia  and  manipulations  of 
the  adnexa,  unnecessary  force  should  be  avoided.  The  possibility 
of  mistaking  an  enlarged  ovarv  for  the  uterus  must  be  remembered 


Fig.  184.  —  Schultze's 
Sledge-shaped  PEiSAEY 
— Two  Shapes  Moulded 
FROM  Celluloid  Eing. 


I'TKIUSK    nisi'LAClCMENTS.  2fi1 


This  caution  also  refors  to  other  tubal  and  cystic  collections  in 
Douglas'  pouch.  Special  care  should  be  taken  if  the  sound  be  vised 
with  an  anfpsthetic. 

3.  The  Jcncc-clbow  pos///oM,  with  the  em}>ty  rectum  and  bladder, 
will  be  found  a  most  valuable  aid  in  replacing  the  uterus  by  the 
bi-manual  method.  When  thus  replaced,  the  pessary  selected,  one 
suitable  in  size  and  shape,  can  be  inserted,  and  supported  by  the 
finger  until  the  patient  is  again  in  the  lateral  position. 

4.  The  sound  is  useful  for  estimating  the  size  of  the  uterus  and 
the  degree  of  flexion  ;  in  the  diagnosis  of  extra-uterine  and  associated 
tumours,  especially  by  the  A'esico-vaginal  and  recto-vesical  methods 
of  examination.  It  is  dangerous  as  a  repositor  where  there  are 
adhesions,  or  the  results  of  recent  pelvic  inflammations.  It  is  not 
justifiable  to  use  force  with  the  sound  in  attempts  to  replace  the 
uterus  with  it,  and  should  it  be  employed  as  a  repositor  it  must  not 
be  rotated  on  its  axis,  but  used  to  raise  the  uterus  in  the  jDroper 
manner.  When  the  sound  has  been  used  for  therapeutic  purposes, 
precautions  should  be  taken  subsequently,  by  enjoining  the  necessity 
for  rest,  avoidance  of  cold  or  exertion,  or  other  indiscretion  on  the 
part  of  the  patient.  The  sound  should  always  be  rendered  aseptic 
before  use.  The  possibility  of  a  retroverted  and  pregnant  womb 
has  always  to  be  borne  in  mind. 

In  the  great  majority  of  cases  the  sound  is  unnecessary  for  the 
purpose  of  diagnosis,  and  only  in  a  certain  proportion  of  cases  is  its 
use  demanded  as  a  repositor  if  the  bi-manual  method  be  carefully 
carried  out. 

5.  Massage. — Should  massage  be  indicated,  the  rectum  and 
bladder  ought  to  be  emptied  beforehand.  It  is  best  administered 
in  the  semi-prone  and  knee-elbow  position.  The  vagina  having  first 
been  douched  out  with  some  antiseptic,  and  the  fingers  of  the 
operator  lubricated  with  lysol,  the  degree  of  force  used  must  be 
carefully  proportioned  and  gradually  increased  in  the  manipulation 
of  adhesions,  according  to  the  sensitiveness  and  resistance  of  the 
uterus,  and  the  relations  and  condition  of  the  adnexa.  The  patient 
being  in  the  knee-elbow  position,  after  the  massage  the  posterior 
cul-de-sac  is  packed  with  ichthyol,  glyco-thyraolin,  and  glycerine  tam- 
pons. (Solution  of  ichthyol  (10  per  cent.)  one  part,  glyco-thymolin 
one  part,  glycerine  three  parts.)  No  pessary  should  be  worn 
until  the  uterus  is  got  into  as  fair  a  position  as  possible.  It  is 
well  for  the  patient  to  assume  for  some  minutes,  a  few  times  in 
the  day,  the  knee-elbow  posture.     All  patients   under  treatment. 


262  DISEASES   OF   WOMEN. 

and  after  the  uterus  has  been  restored  to  its  normal  position,  should 
be  directed  to  empty  the  bladder  at  regular  intervals. 

6.  Curettage. —  The  most  important  step  towards  the  cure  of 
many  cases  of  retroversion,  especially  those  in  which  some  form  of 
endometritis,  with  enlargement  of  the  uterus,  hyperplastic  or  other- 
wise, complicates  the  displacement,  is  thorough  curettage.  The 
necessary  dilatation  of  the  uterine  canal,  the  reduction  of  congestion, 
and  the  general  improvement  in  the  size  of  the  uterus  and  the  state 
of  the  adnexa  which  usually  follow  a  complete  curetting,  render  the 
restoration  of  the  uterus  to  its  position  more  easy,  facilitate  the 
carrying  out  of  any  necessary  manipulations,  and  render  the  cure 
more  permanent  and  satisfactory, 

7.  Displacements  that  do  not  yield  to  such  palliative  treat- 
ment, that  pessaries  fail  to  cure,  that  are  complicated  with 
disease  of  the  adnexa,  that  cause  symptoms  seriously  interfering 
with  the  health  of  the  woman,  and  which  prevent  her  follow- 
ing her  avocation,  demand  operative  interference,  and  such  opera- 
tive interference  will  be  largely  influenced  in  its  nature  and 
technique  by  the  associated  conditions  and  the  circumstances  of 
the  patient. 

Operative  Treatment, — By  prolonged  perseverance  in  treatment, 
by  local  absorbents,  massage,  the  assistance  of  posture,  curettage 
and  a  pessary,  we  frequently  cure  completely  cases  which  at  first 
appeared  almost  incurable.  Recalling,  however,  the  number  of 
those  in  whom  there  has  been  no  such  satisfactory  issue,  and  the 
time,  sufieiing,  and  inconvenience  involved,  I  should  now  in  the  first 
instance  advise  operation  in  all  extreme  cases  of  retroversion,  while 
an  expectant  course  is  altogether  out  of  the  question  in  the  instance 
of  poorer  patients. 

Among  the  most  valuable  papers  on  the  subject  of  operation 
jjublished  within  recent  years  are  those  of  Delageniere,*  (Le  Mans) 
and  Goldspohn,t  of  Chicago,  International  Congress  of  Gynaecology 
and  Obstetrics,  Amsterdam,  1899;  June,  1900  jt  Kohn's  paper 
read  before  the  Munich   Congress  in  1897;    a  paper  by  J.  Veit, 

*  'Du  raccourcissement  des  ligaments  larges  et  des  ligaments  ronds  dans  la 
retroversion  de  I'uterus.'  Dr.  Henri  Delageniere.  Comptos  Reudusdu  Congres 
Internationale  de  Gynsecologie  et  d'Obstetrique,  Amsterdam,  1900. 

t  Goldspohn,  Amer.  Gyn.  and  Ohstet.  Jour.,  June,  1900. 

X  'Indications,  Technique,  and  Eesults  of  an  Improved  Alexander  Operation 
in  Aseptic,  Adherent,  Retroversions  of  the  Uterus,  when  combined  with  Inguinal 
Cceliotomy,  via  Dilated  Internal  Inguinal  Ring.'  By  A.  Goldspohn,  M.D.,  Pro- 
fessor of  Gynaecology,  Chicago,  Post  Grad.  Med.  School,  etc.  ' 


UTERINE    nrSPLACEMENTS.  263 


in  June,  1900;"'  and  those  already  referred  to  of  Rissman  and 
Flaischlen  (Zeitscrift  f.   Ohir.,  Bd.  LVIII.,  H.  3  and  4) ;  Mazadc 

{Znttralh.f.  Gyn.,  1903,  No.  26)  ;  Martin  (PMladelpMa  Med.  Jour., 
June  15,  1901);  Le  Roy  Broun  (iVr/«  Yorh  Medical  Bccord,  1902, 
Feb.  2);  Kuhne  (Cnitralb.  f.  Gyn.,  1901,  No,  T.) ;  Carl  Peters, 
Dresden  (Murnch  Med.  Wochensehrlft,  1900,  S.  11G3). 

Most  valuable  contributions  have  also  been  made  by  Hohl  (Archii:. 
f.  Gtjn.,  1897)  ;  Boralevi  ('  Annali  di  Obstetricia  e  Genecologia,' 
Sept.,  1897);  Luigi  Negri  ('Annali  di  Obstetricia  e  Gen.,'  1896); 
Lapthorn  Smith  (Amcr.  Gyn.  Soc,  May,  1897)  ;  Miiller's  Operation 
(paper  by  F.  Edge,  Brit.  Gyn.  Jour.,  Aug.,  1896)  ;  Lapthorn 
Smith  {Amer.  Jour.,  Ohstet.,  1898)  ;  Howard  Kelly  ('  Operative 
Gynaicology,'  1898). 

Choice  of  Operation. 

The  vital  points  with  regard  to  operation,  once  it  be  determined 
upon,  are  :  (1)  that  method  most  suitable  to  the  mobile  and  reducible 
uterus  during  and  after  the  child-bearing  period  ;  (2)  that  appropriate 
to  retroflexion  with  adnexal  complications  and  adhesions ;  (3)  the 
bearing  of  the  particular  method  on  child-bearing,  and  the  conse- 
quences which  may  follow  to  the  parturient  woman  during  labour. 

Abroad,  either  Alexander's  or  the  Alexander- Adams  operation, 
with  various  and  important  modifications,  extra-peritoneal  or  intra- 
peritoneal, is  preferred  by  such  well-known  gynsecologists  as  Doleris, 
Cohn,  Kustner,  Kronig,  Veit,  Carl  Peters,  Delageniere,  Bamberger, 
Stocker,  Fiith,  Rumpf,  Kocher,  Doyen,  and  others ;  in  America  by 
quite  a  number  of  surgeons,  including  Goldspohn,  Edebohls,  Mund^, 
Martin  (Chicago),  Le  Roy  Broun,  Parker  Newman,  and  Kellog,  while 
Lapthorn  Smith,  of  Montreal,  has  performed  a  very  large  number 
of  operations  by  this  method. 


Various  Operative  Procedures. 

To  enter  into  details  of  the  various  operative  procedures  suggested  by 
various  surgeons,  in  no  matter  how  brief  a  manner,  is  obviously  impossible.  I 
must  content  myself  with  a  rather  imperfect  classification,  based  on  the  broad 
principles  on  which  each  operation  is  devised.  The  first  are  those  operations 
in  which  the  round  ligament  is  fixed,  as  by  the  original  Alexander- Adams 
method,  to  the  external  abdominal  ring,  or  the  aponeurosis  of  the  external 
oblique  muscles,  and  the  various  modifications  of  this  operation,  some  of 

*  J.  Veit,  Berliner  Klin.  Wochen.,  June  11,  1900. 


264  DISEASES   OF    WOMEN. 

which  mainly  consist  in  further  interference  with  the  inguinal  canal,  either 
partially  or  for  its  entire  length,  and  the  mode  of  fixation  of  the  round 
ligament,  into  the  processus  vaginalis  peritonei  (Kustner).  Or  the  opera- 
tion proposed  hy  GoldspoJin,  in  which,  after  sufficient  enlargement,  the 
round  ligament  is  traced  to  its  place  in  the  broad  ligament,  and  the  internal 
inguinal  ring  stretched  and  dilated,  is  utilized  for  abdominal  exploration  and 
manipulations,  or,  if  necessary,  removal  of  diseased  structures.  Finally,  by 
purse-string  sutures,  the  round  ligament,  the  peritoneum,  and  inguinal  ring 
are  united,  the  entire  structures  consisting  of  the  round  ligament,  with  the 
internal  ring,  and  the  surrounding  muscular  structures  of  the  internal  oblique 
and  transversalis  muscles,  being  anchored  to  Poupart's  ligament.  There  is  the 
operation  as  prar.tised  hy  BeJageniere,  Mann,  and  several  others,  in  which  the 
round  ligaments  are  reached  by  an  abdominal  incision,  when  they  are  looped 
or  folded  upon  themselves,  and  fixed  to  the  line  of  Poupart's  ligament  or  to 
the  aponeurosis  and  walls  of  the  canal.  Others  again  include  the  loop  in  that 
which  ties  off  the  adnexa  when  these  are  removed.  Edebohls  opens  up  the 
inguinal  canal  for  its  entire  length,  and  having  shortened  the  ligaments, 
anchors  the  various  structures  round  the  internal  ring  to  Poupart's  ligament, 
including  in  the  attachment  the  external  ring  and  the  external  oblique  apo- 
neurosis. The  Landaus  fix  the  broad  ligaments  to  the  peritoneum  and  sub- 
peritoneal fascia,  not  the  uterus,  reserving  any  fixation  of  the  latter  for  after 
the  child-bearing  period  of  life.  Martin,  of  Chicago*  following  on  the 
suggestion  of  Fowler  to  suspend  the  uterus  from  the  urachus,  dissects  off"  a 
strip  of  loeritoneura  half  an  inch  wide  and  three  inches  in  length  from  the 
abdominal  wall.  The  freed  uterus  is  now  sutured  at  the  fundus  by  passing 
the  thread  from  behind  forward,  and  attaching  it  with  the  strip  of  peritoneum 
to  the  peritoneal  surface  of  the  abdominal  wound  above  the  uterus.  A  few 
small  catgut  sutures  also  retain  the  latter  in  its  position. 

All  these  operations,  and  others  of  a  similar  nature,  agree  in  the 
principle  that  the  uterus  shall  be  held  in  position  by  the  round 
ligaments  alone,  or  with  the  structures  with  which  they  are  con- 
nected in  the  inguinal  canal,  and  that  the  point  of  attachment  or 
suspension  be  either  to  the  external  abdominal  ring  and  aponeurosis 
or  Poupart's  ligament.j 

In  the  second  class  of  operations  the  uterus  itself  is  fixed  either 

*  Phil.  31ed.  Jour.,  June  15,  1901. 

t  Quoting  from  Cobn.  Nicholson  says: — 'It  is  interesting  to  note  that  the 
operation  of  shortening  the  round  ligaments  was  first  performed  by  Alquie', 
in  the  year  1840,  in  order  to  support  a  prolapse,  and  by  Aran,  who  treated  a 
retro-displaced  organ  in  this  way.  Franco,  however,  was  not  the  country  in 
which  the  merit  of  the  operation  was  first  established,  since  the  procedure  was 
allowed  to  lapse  until  many  years  later,  and  was  then  re-introduced  elsewhere. 
In  Germany,  Laugenbeck  and  Freund  were  the  first  advocates,  but  to  Alexander 
and  Adams  the  real  credit  belongs.  Cohn,  from  the  results  of  the  Breslau  clinic, 
regards  the  Alexander-Adams  as  the  best  form  of  operation  during  the  period 
of  possible  conception.'     (^Zeits.  f.Gfburf.  u.  Gyn.,  Bd.  XLIIL,  H.  3.) 


UTERINE  DISPLACEMENTS.  2C5 


extra-peritoneally  to  the  vagina,  as  in  the  operation  of  Miiller  and 
Diihrssen,  or  by  tho  intraperitoneal  vaginal  fixation,  by  August 
Mai'tin.  There  is  tlie  mctliod  of  Vinebcrg  in  which  vaginal  fixation 
of  the  round  and  broad  ligaments  is  secured  by  anterior  colpotomy. 
In  the  third  class  we  include  those  operations  of  fixing  the  uterus  to 
the  abdominal  wall,  either  by  the  direct  mesial-fixation  methods 
of  Leopold,  Czerny,  Pozzi,  and  others,  or  the  lateral  fixations  of 
Olshausen  and  Sanger,  or  the  uterine  suspension  method  of  Howard 
Kelly,  by  which  the  uterus  is  fixed  to  the  peritoneum  and  sub- 
peritoneal fascia.  The  operation  of  Mackenrodt,  in  which  the 
uterus  is  attached  to  the  posterior  surface  of  the  bladder,  is  one 
which  has  not  been  largely  adopted. 

N.  J.  Hawley  *  strongly  advocates  vesico-fixation  from  tlie  point  of  view 
that  the  accompanying  colpotomy  affords  ample  opportunity  of  dealing  with 
the  adnexa  and  adhesions,  as  well  as  any  endometritis  that  may  be  present. 
There  is  less  danger  to  the  patient,  speedier  recovery,  and  absence  of  the 
abdominal  scar.  The  first  steps  of  the  operation  are  practically  A.  Martin's 
anterior  colpotomy.  When  the  edge  of  the  bladder  is  separated  from  the 
uterus,  it  is  stitched  high  up  on  the  anterior  surface  of  the  latter,  with  a 
single  chromicized  mattress  suture,  and  the  vaginal  wound  closed  over  this 
with  interrupted  catgut. 

Tightening  the  Broad  Ligaments. 

Harris  Slocum  f  suggests  the  removal  of  a  triangular  portion  of  the  hroad 
ligament,  or  buttonholing  it  either  through  the  parovarium  on  one  side,  or 
the  broad  ligament  on  the  other.  'When  the  object  is  simply  to  correct  the 
backward  displacement  after  adhesions  are  broken  up  and  the  fundus  drawn 
forwards,  by  making  traction  on  the  broad  ligaments,  it  ma}'  suffice  to  shorten 
the  latter  by  simply  making  a  fold  on  either  side,  modifying  the  extent  and 
shape  of  this  according  to  circumstances.  A  V-shaped  fold,  inverted,  if  it  be 
desired  to  raise  the  uterus  as  well  as  the  fundus,  is  recommended.  Modifica- 
tions of  the  operation  will  depend  upon  the  necessity  for  removing  the  ovaries 
and  oviducts.  Should  this  be  necessary,  he  ligatures  the  ovarian  vessels  at 
the  pelvic  wall,  and  then  excises  the  oviduct  for  its  entire  length,  a  V-shaped 
portion  of  broad  ligament  being  removed  at  its  outer  extremity.  The  ovaries 
may  be  removed  through  the  same  incision.  The  size  and  direction  of  the 
buttonholes,  if  this  plan  he  adopted,  will  depend  upon  circumstances.  He 
suggests  calling  the  operation  '  cuneiform  shortening  of  the  broad  ligaments.' 

Shortening  of  the  Sacro-Uterine  Ligaments. — Within  the  last 
few  years  prominence  has  again  been  given  to  the  treatment  of 
retroversion  and  retroflexion,  as  well  as  prolapse  of  the  uterus,  by 
operation  on  the  utero-sacral  folds. 

*  Amer.  Gyn.,  May,  1903.  t  Und.,  July,  1903. 


266  DISEASES   OF   WOMEN. 

Bovee  *  has  collected  the  statistics  of  ninety-one  operations,  the  great 
majority  of  which  were  performed  for  retroversion.  His  own  operations 
were  performed  between  the  years  1897  and  1902.  The  idea  of  treating 
both  retroversion  and  prolapse  of  the  uterus  by  operating  upon  the  utero- 
sacral  ligaments  commenced  with  Amussat's  first  attempts  with  caustic  potash 
and  cautery  in  1850.  Herrick,  Byford,  Freund,  Formell,  Sanger,  Wertheim, 
and  Mandl,  operated  both  by  the  abdominal  and  vaginal  routes.  Jessett  and 
Stanmore  Bishop  revived  the  principle  of  the  operation  in  England,  the  latter 
more  particularly  for  prolapse,  and  in  cases  where  the  hgaments  are  lacerated 
or  torn  through.  His  operation  is  performed  through  the  abdomen.  (See 
'  Prolapsus  Uteri.')  The  details  of  Bovee's  operation,  and  that  of  Bishop,  will 
be  found  under  the  head  of  '  Prolapsus  Uteri.' 

Practically,  then,  we  come  to  (1)  the  operation  of  Alexander,  or 
the  Alexander- Adams,  with  the  various  modifications  of  his  method, 
extra-jDeritoneal  and  intra-peritoneal ;  (2)  ventro-fixation  ;  (3)  sus- 
pension of  the  uterus  by  Kelly's  method,  and  (4)  vagino-fixation. 
Foi-  my  own  part,  operating  only  in.  cases  in  which  there  are  such 
complications  or  conditions  as  absolutely  demand  interference,  I 
have  adopted  either  ventro-fixation  or  suspension  of  the  uterus,  as  I 
feel  that  coeliotomy  affords  the  best  and  safest  means  of  correcting 
the  majority  of  adnexal  complications  should  they  exist,  while 
experience  does  not  appear  to  have  shown,  from  statistics  of  the 
results,  that  there  is  greater  danger  to  pregnancy  than  by  any 
other  methods.  However,  given  a  case  of  mobile  aud  reducible 
uterus,  there  can  be  no  doubt  that  the  Alexander-Adams  operation 
is  on  all  grounds  the  classical  method  of  dealing  with  the  condition. 
The  mortality  of  either  uncomplicated  operation  is  practically  nil. 

Of  1140  operations,  the  records  of  which  I  have  gone  into,  I  find  but  two 
cases  died.  Many  operators  loop  intra-peritoneally  the  round  ligaments,  as 
originally  advocated  by  Delageniere,  Mann,  and  Jacobs,  or  it  is  fixed  into  the 
loop  which  ties  off  the  ovary  and  tabe,  should  these  be  removed  (Lapthorn 
Smith).  On  the  other  hand,  some  operators  fix  the  broad  and  round  liga- 
ments to  the  parietal  peritoneum.  Vineberg's  operation  of  vaginal  fixation 
of  the  broad  and  round  ligaments  hav«  not,  in  that  operator's  hands,  been 
followed  by  any  death.  Howard  Kelly,  in  his  utero-suspension  cases,  has 
not  had  more  than  1  per  cent,  of  failures. 

If  we  review  the  statistics  of  a  number  of  operators,  the  choice 
appears  to  lie  mainly  between  four  procedures,  or  the  modifications 
of  these.  (1)  The  Alexander-Adams  operation,  or  some  one  of  its 
modifications  ;  (2)  ventro-fixation ;  (3)  utero-suspension ;  and  (4) 
vagino-fixation. 

*  Amer.  Jour.  Obstet.,  July,  1902  ;  Annals  Gyn.  and  Peel,  Dec,  1902. 


UTERINE  DISPLACEMENTS. 


Alexander's  Operation. 

Alexander  himself  has  not  to  any  great  extent  modified  his 
original  operation  in  any  case  in  which  the  uterus  is  movable.  He 
insists  that  he  never  recommends  it  for  an  adherent  uterus,  and 
that  it  may  be  contra-indicated  in  diseased  conditions  of  the  adnexa. 
In  such  cases  he  performs  a  preliminary  vaginal  coeliotomy,  explor- 
ing the  pelvis  and  separating  adhesions.  With  rare  exceptions  he 
has  not  found  it  difficult  to  discover  the  ligaments,  the  guide  being 
the  clear  glistening  aponeurosis  of  the  external  oblique  outside  the 
external  ring.  If  the  ligament  be  not  seen  lying  below  over  the 
lower  pillar,  he  divides  the  transverse  fibres  so  as  to  expose  it, 
cutting  the  nerve  and  pulling  it  gently  out  with  the  fingers.  He 
emphasizes  the  necessity  for  straightening  the  uterus  before  opera- 
ting in  old  retroflexion,  using  a  galvanic  stem  supported  on  a  Hodge, 
which  is  retained  for  three  weeks,  the  patient  being  in  bed.  He 
retains  the  lever  pessary  for  two  or  three  months,  requiring  the 
patient  to  be  seen  one  week  after  it  is  removed,  and  once  every 
month  subsequently  for  some  months. 

The  steps  of  Alexander's  original  operation  are  as  follows  : — 

1.  An  incision,  varying  in  length  and  depth  according  to  the 
thickness  of  the  abdominal  wall,  and  the  amount  of  adipose  tissue, 
upwards  and  outwards,  so  as  to  expose  the  tendon  of  the  external 
oblique  muscle. 

2.  The  search  for  and  exposure  of  the  external  abdominal  ring, 
and  section  of  the  oblique  and  inter-columnar  bands. 

3.  Exposure  of  the  end  of  the  round  ligament,  and  the  freeing  of 
it  from  the  surrounding  fatty  tissue. 

4.  Careful  isolation  of  the  ligaments  from  the  surrounding  tissue, 
and  freeing  it  from  any  adhesions,  so  as  to  enable  the  operator  to 
pull  on  the  ligaments  and  draw  them  forward  to  the  required  extent. 

All  these  steps  have  to  be  taken  cautiously  and  gently.  Rough- 
ness or  unnecessary  force  may  rupture  the  ligaments  and  tear  their 
thinner  ends. 

5.  The  uterus  is  now  placed  in  position  by  a  sound  or  obturator, 
or  by  the  fingers  of  an  assistant,  and  at  the  same  time  another 
assistant  draws  each  ligament  out  to  the  required  extent,  while  it 
is  being  stretched  to  the  pillars  of  the  ring  by  suture  passed  from 
one  pillar  to  the  other,  embracing  the  ligament  in  its  passage. 
Alexander  prefers  silkworm  gut.     These  sutures  are  buried. 

6.  The  loose  ends  of  the  ligaments  are  now  cut  off,  all  bleeding 


268  DISEASES   OF   WOMEN. 

is  arrested,  and  the  wound  is  closed.     A  Hodge  is  placed  in  the 
vagina.     The  wound  usually  heals  by  first  intention. 

Modified  Alexander-Adams  Operation. — I  may  now  describe  the 
operation  as  I  perform  it.     It  gives  me  complete  satisfaction  : — 

The  operation  is  a  modification  of  those  of  Edeboiils,*  Kocher,  of  Berne, 
and  Parker  Newman  of  Chicago.  The  first-named  opens  the  canal  for  its 
whole  length,  guarding  the  ilio-inguinal  nerve  in  drawing  out  the  ligament, 
slipping  back  the  inverted  peritoneum,  and  shortening  the  ligaments  from 
7  to  10  cm.     The  technique  of  the  operation  is  as  follows  : — 

The  first  three  steps  of  the  operation  are  the  same  as  those  just  described. 
The  inguinal  canal  is  now  opened  as  far  as  the  internal  abdominal  ring,  which 
is  sought  for,  and  dilated  with  the  finger.  The  round  ligament  is  next  freed 
and  isolated  as  far  as  the  internal  abdominal  ring,  and  made  to  run  free  from 
any  attachments.  The  uterus  is  then  anteverted  by  the  fingers  of  an  assistant, 
or  by  the  uterine  elevator.  The  round  ligament  is  drawn  well  forward,  and, 
by  a  series  of  interrupted  cumol-gut  sutures,  is  fixed  from  the  internal  abdo- 
minal ring  downwards  in  the  canal,  the  lower  portion  being  attached  to  the 
pillars  of  the  external  abdominal  ring.  The  lower  loose  end  is  next  cut  off, 
and  the  proximal  end  is  sutured  to  the  aponeurosis.  These  sutures  are  now 
tied,  and  the  canal  is  thus  completely  closed.  Perfect  union  having  been 
secured,  the  skin  is  closed  with  celloidinzwirn  or  bronze  aluminium  wire.  The 
same  technique  is  followed  on  the  other  side.  The  wounds  are  dusted  with  some 
dermatol  powder,  over  which  sterilized  iodoform  gauze  and  wool  are  placed.  A 
double  spica  bandage  is  applied,  and  the  patient  placed  in  bed  with  her  knees 
supported  on  a  pillow.  Scrupulous  asepsis  being  maintained,  the  wound 
heals  by  first  intention.  A  light  celluloid  Hodge  is  placed  iu  the  vagina  after 
the  first  few  days,  and  this  is  retained  for  some  weeks.  Personally,  I  reserve 
this  operation  for  cases  of  moMle  uterus  vjithout  adhesions  and  a'lnexal 
complications  in  women  dvring  the  child-hearing  period.  There  is  no 
possibility  of  a  hernia  following  such  an  operation  as  that  described. 

Keviewing  the  statistics  of  some  thousands  of  cases  of  the  Alexander- 
Adams  operation,  performed  by  different  methods,  we  maj'  arrive  at  the 
following  conclusions  : — 

The  mortality  at  the  outside  does  not  amount  to  1  per  cent.  With 
scrupulous  asepsis  union  generally  occurs  by  the  first  intention,  and  sinuses 
from  suppuration  are. rare.  The  results  in  pregnancy  and  during  labour  are 
excellent.  If  the  ligaments  be  thoroughly  secured  and  anchored,  relapses 
do  not  occur.  Few  have  a  larger  experience  of  the  operation  than  Lapthorn 
Smith  (Montreal),  and  his  results  completely  verify  these  conclusions. 

Other  Methods. — The  intra-ahdominal  method  which  he  practises  is  prac- 
tically that  of  Olshausen,  the  ligament  being  looped  up  and  tied  into  the  loop 
which  ligatures  off  the  ovary  and  Fallopian  tube,  should  it  be  necessary  to 
remove  these.  Otherwise  the  ligament  is  simply  shortened  by  drawing  up  a 
loop  of  it  and  stitching  it  to  itself  for  a  space  of  about  two  inches.  Or, 
the  loop  having  been  formed,  the  ligament  may  be  anchored  to  the  sub- 
peritoneal fascia  and  peritoneum. 

*  Amer.  Gyn.  and  Obstet.  Jour.,  Dec,  1896. 


UTERI XE   DISPLACEMENTS.  2G9 


Transverse  Incision. 

Villard  modifies  Alexander's  operation  hi/  makiuij  the  incisio/t  a  transuerse 
one,  from  one  inguinal  canal  to  tlie  other,  drawing  the  round  ligaments  for- 
ward, tying  these  together,  and  securing  them  by  sutures  to  the  symphysis, 
and  also  to  the  external  abdominal  rings.  Schucking  opens  the  vaginal 
vesico-uterine  fold,  transfixing  the  broad  ligament  with  a  large-handled 
needle,  and  passing  the  thread  round  the  fundus  uteri,  transfixing  the  other 
broad  ligament,  thus  bringing  the  thread  forward,  and  knotting  it  in  the 
anterior  vaginal  wall.  Wertheim,  Bode,  and  Koblanck  fix  the  round  luja- 
mentii  in  the  vagina. 

Baldy's  Operation. — Baldy  picks  up  tlie  round  ligaments  on  each  side  of  the 
uterus,  and  ligatures  these  close  up  to  it,  thus  securing  the  artery.  The  lio-a- 
ments  are  then  divided  near  the  ligatures.  Bleeding  having  been  controlled 
by  ligaturing  the  vessels,  the  broad  ligament  is  perforated  by  forceps,  and 
the  divided  pelvic  end  of  the  round  ligament  is  pulled  through  the  aperture 
until  it  appears  on  its  posterior  side.  The  ligaments  of  the  two  sides  are 
treated  alike.  Their  cut  ends  are  attached  by  sutures  to  the  posterior 
aspect  of  the  cornua  of  the  uterus,  directly  behind  the  original  point  of 
attachment  of  the  ligament. 

Newman,  of  Chicago^  having  thoroughly  freed  both  ligaments,  leavino-  a 
loop  of  ligament  some  four  inches  in  length  at  either  side,  stitches  it  together, 
fastening  the  ligament  into  the  aponeurosis  and  wall  of  the  inguinal  canal  by 
buried  gut  sutures.  Lapthorn  Smith  does  not  open  the  inguinal  canal,  and 
does  not  cut  a  single  fibre  of  the  inter-columnar  fascia,  but  he  is  most  careful 
in  discriminating  the  cases  which  require  ventro-fixation  or  uterine  suspension 
from  those  which  can  be  treated  by  the  Alexander  method.  Taylor  of 
Birmingham  uses  fine  ophthalmic  silk  as  a  buried  suture,  to  close  entirely 
the  wound  in  the  external  oblique,  and  to  sew  the  upper  end  of  the  li<'-ament 
to  the  under  surface  of  the  aponeurosis. 

Noble's  Operation. — G.  H.  Noble  *  adopts  the  transverse  incision  down  to 
the  outer  edge  of  each  rectus  muscle,  separating  these  latter  and  then  opening 
the  peritoneum.     The  remaining  steps  of  the  operation  are  as  follows  : f 

(1)  With  light  forceps  one  of  the  round  ligaments  is  grasped  about  the 
middle  of  its  intraperitoneal  portion  ;  by  traction  on  the  forceps  the  uterus  is 
pulled  somewhat  to  that  side  of  the  pelvis  which  is  opposite  the  li"-ament 
held,  the  peritoneum  is  drawn  away  from  the  region  of  the  internal  abdominal 
ring,  and  the  ligament  made  taut,  so  that  it  may  be  the  more  readily  recoo-- 
nized  in  the  extraperitoneal  manipulations  to  follow.  (2)  Just  beyond  the 
outer  edge  of  the  rectus,  at  the  end  of  the  transverse  incision,  the  point  of  a 
pair  of  artery  forceps  is  thrust  through  the  posterior  sheath  of  the  muscle 
but  does  not  enter  the  abdomen.  The  forceps  is  opened  and  withdrawn  so 
that  an  aperture  large  enough  to  admit  the  index  finger  is  left.     The  finger  is 


*  Armr.  Jour.  Obstet.,  Feb.,  1903. 

t  Kustner  had  been  cue  of  tlie  first  to  adopt  the  transverse  iacision.     Kuhne 
(Marburg)  subsequently  reported  ou  it  (CcntraVi.  f.  Gyn.,  1901,  No   I). 


270  DISEASES   OF    WOMEN. 

introduced  into  the  subperitoneal  fat  and  feels  the  round  ligament  without 
difficulty,  for  it  is  brought  into  prominence  by  tension  on  the  forceps  which 
holds  its  uterine  end.  (3)  The  finger,  passed  through  the  opening,  is  hooked 
under  the  extraperitoneal  portion  of  the  ligament  from  below  upward,  and 
draws  it  up  into  the  wound.  The  sheath  of  the  ligament  is  then  split  open 
by  blunt  dissection.  The  sheath  and  the  peritoneum  are  stripped  back  in  the 
direction  of  the  uterus,  completely  divesting  the  ligament  of  its  covering.  It 
is  then  drawn  out  of  the  wound,  and  forceps  is  slipped  underneath,  to  retain 
it,  until  the  opposite  ligament  has  been  raised  and  denuded  in  the  same  way. 
If  the  uterus  has  been  in  marked  retroversion,  the  ligaments  will  have 
become  so  attenuated  as  to  allow  their  approximation  in  the  median  line  in 
front  of  the  recti,  which  approximation  will  restore  the  uterus  to  its  normal 
position.  (4)  The  peritoneum  of  the  median  incision  and  the  recti  muscles 
are  closed  with  continuous  kangaroo  or  catgut  sutures.  (5)  The  ligaments 
are  approximated  in  front  of  the  recti  and  tied  together.  (6)  The  cut  edges 
of  the  aponeuroses  are  stitched  together.  When  one  or  two  loops  of  the 
suture  have  been  passed,  the  needle,  in  crossing  the  interval  between  the 
two  edges,  is  made  to  pass  through  the  ligament.  This  process  is  continued 
as  each  successive  loop  is  passed  until  the  centre  of  the  incision  is  reached, 
when  the  free  end  of  the  suture  is  clamped  and  left  long.  Starting  from  the 
other  end  of  the  transverse  incision,  a  second  strand  of  kangaroo  tendon 
unites  the  edges  of  the  aponeurosis  on  that  side  and  picks  up  the  round 
ligament.  The  kangaroo  tendons  are  tied  togetherj  and  the  ligaments  are 
thus  embedded  and  firmly  anchored  between  the  aponeurosis  and  muscles, 
where  they  contract  extensive  adhesions. 

Ventro-fixation. — This  operation  should  only  be  performed  on 
women  past  the  child-bearing  period. 

The  usual  aseptic  precautions  having  been  taken,  and  the  mons 
veneris  carefully  shaved,  an  incision  from  two  and  a  half  to  three 
inches  in  length  is  made.  The  peritoneum  is  opened,  two  fingers  of 
the  left  hand  are  carried  well  down  behind  the  uterus,  and  its 
position  and  mobility  determined.  The  adnexa  of  either  side  are 
brought  up  and  examined,  and,  should  they  be  diseased,  the 
puncturing,  resection,  or  extirpation' of  the  cysts  is  determined  upon. 
The  uterus  is  now  raised  with  the  fingers  and  brought  forward,  and 
there  is  usually  no  difficulty  in  this  manoeuvre.  The  summit  is  now 
lightly  caught  by  a  single  tenaculum.  The  first  suture  of  gut  is 
passed  through  the  sheath  of  the  rectus,  the  muscle,  sub-peritoneal 
fascia,  and  peritoneum,  and  is  carried  about  an  inch  beneath  the 
summit  through  the  posterior  wall,  taking  in  sufficient  of  the  latter 
to  secure  the  suture.  Another  fairly  strong  gut  suture  is  carried 
through  the  anterior  surface  of  the  fundus,  a  short  distance  from 
the  summit,  and  a  third,  if  it  be  thought  needful,  is  passed  one  inch 
beneath  this.     These  sutures,  clipped  together  with  catch  forceps, 


UTKHINE  DISPLACEMENTS. 


m 


are  allowed  to  remain  loose.  The  peritoneum  is  now  closed  by  tino 
interrupted  sutures  of  silk  ;  the  margins  of  the  raised  rectal  sheath 
and  muscle  are  next  carefully  brought  together  and  united  in  the 
middle  line.  The  three  original  sutures  arc  now  tied,  and,  finally, 
the  skin  is  closed. 

Suspension  of  the  Uterus. — ^This  is  a  totally  different  procedure 
in  principle  and  detail  of  technique  from  ventro-fixation.  The 
uterus  is  attached  to  the  peritoneum  and  sub-peritoneal  fascia,  and 
is  thus  suspended.  An  incision,  similar  to  that  in  the  fixation 
operation,  is  made,  and  the  peritoneum  opened.  The  uterus  is 
hooked  up  and  lifted  forward  by  the  fingers,  and  the  ligatures  are 
passed  through  the  peritoneal  and  sub-peritoneal  fascia,  through  the 
fundus  of  the  uterus  on  its  posterior  face  a  short  distance  from 
the  summit,  being  carried 
through  cor  responding 
points  of  the  peritoneum 
and  sub-peritoneal  fascia 
on  the  opposite  side.  These 
sutures  are  caught  with 
hasmostatic  forceps  at 
either  side.  The  wound 
having  been  carefully 
cleansed  with  dabs  wrung 
out  of  formalin  (a  few  of 
which  are  passed,  with 
light  clamp  forceps  as 
spongeholders,  behind  the 
uterus  to  dry  off  any 
blood),  the  omentum  is  carefully  replaced,  the  peritoneum  is  sewn 
up  with  continuous  fine  suture  of  cumol  gut,  the  uterine  ligatures 
being  tied  en  route.  The  fascia  is  next  detached  from  the  rectus 
muscle,  and  carefully  united  with  stronger  cumol  gut  in  another 
continuous  suture,  the  skin  being  closed  with  celloidinzwirn  or  silk- 
worm gut. 

It  is  to  be  preferred  to  the  Alexander- Adams  in  cases  in  which 
there  is  any  suspicion  of  diseased  conditions  of  the  adnexa,  and 
where  there  are  adhesions ;  and  to  "  fixation,"  when  there  is 
any  possibility  of  conception — indeed,  all  through  the  child- 
bearing  period ;  again,  in  cases  where  the  uterus  is  enlarged,  and 
it  may  be  necessary  to  enucleate  a  small  myoma  embedded  in 
its    wall.       Howard    Kelly,    who    initiated    the    operation,    passed 


Fig.  185. — Ligatures  passed  TmsouGH  Peri- 
toneum A^TD  Uterus.     (Howard  Kelly.)  I 


272 


DISEASES   OF   WOMEN. 


the  ligatures  through  the  uterus  below  the  fundus,  on  its  posterior 

face. 

Uterine  Suspension  by  the  Round  Ligaments. — The  operation  I 

now  perform  is  different  from  the  last,  inasmuch  as  the  body  of  the 

uterus  is  not  in- 
volved. The  pre- 
liminary steps  are 
the  same.  After  the 
adnexa  have  been 
examined,  and  dealt 
with  if  necessary, 
and  the  uterus  has 
been  brought  for- 
ward, the  round  liga- 
ment at  one  side  is 
hooked  up  on  the 
finger,  and  a  fairly 
thick  cumol  gut  liga- 
ture  is  carried 
through  the  perito- 
neum and  sub-peri- 
toneal fascia  with  a 
cui'ved   needle,  tak- 

FlG.    186.-UTERUS    SUSPENDED,      (HOWAKD    KeLLY.)  -^^    -^    ^^^^    ^j^^^   ^£ 

the  loop  of  the  ligament.  The  two  ends  of  the  ligature  are  caught 
in  a  haemostatic  forceps,  and  allowed  to  drop  over  the  side.  The 
same  procedure  is  carried  out  on  the  opposite  side.  The  wound  and 
pelvic  cavity  are  carefully  cleansed.  The  inner  end  of  one  of  the 
ligatures  is  now  carried  from  within,  out  through  the  peritoneal  and 
sub-peritoneal  fascia  of  the  opposite  side,  and  the  same  is  done  with 
the  other.  Thus  the  two  ligatures  cross  each  other,  either  holding 
a  loop  of  the  round  ligament  close  to  the  uterine  cornua.  The 
peritoneum  is  now  sewn  up  with  cumol  gut,  and  the  round  ligament 
ligatures  are  tied  en  route.  The  remaining  part  of  the  toilet  is  the 
same  as  in  the  other  operation. 


Vaginal  Fixation, 

Extra-peritoneal  Vagino-fixation  (Miiller's  Operation).* — After 
preliminary  curetting  of  the  uterus,  and  application  of  50  per  cent. 

*  From  Edge's  adaiiiable  description  of  the  operation  {Brit.  Gyn.  Jo?<r.,  Aug., 
1896). 


UTERTNK  DISPLACEMENTS.  273 

solution  of  carbolic  acid,  which  should  not  l)e  omitted  on  account 
of  the  frequent  co-existence  of  endometritis  with  backward  dis- 
placements of  the  uterus,  and  likewise  because  of  the  possibility  of 
a  suture  entering  the  uterine  cavity,  and  consequent  danger  of 
infection,  the  uterus  is  pushed  into  the  position  of  anteflexion  by 
means  of  Orthmann's  instrument  (Fig.  188)  and  drawn  strongly 
downwards.  The  anterior  vaginal  wall  is  then  cut  from  the  point 
of  its  insertion  into  the  cervix  up  to  the  meatus  urethras,  but  not 
reaching  the  latter  by  2  cm.  If  cystocele  be  present,  a  vertical 
oval  of  mucous  membrane  is  marked  out  and  at  once  removed. 

The  author  preferably  carries  this  denudation  close  to  the  urethra, 
so  as  to  remove  the  strong  protrusion  of  the  urethra  so  often  left 
after  labours,  and  which  is  the  earliest  sign  of  prolapse  of  the 
anterior  vaginal  wall. 

After  this  the  bladder  is  separated  from  the  vagina  through  the 


Fig.  187.— Orthjiaxs's  Instkuuext. — Combination  of  Socxd 
AXD  Claw  Forceps. 

incision,  and  with  the  haft  of  a  knife  from  the  cervix  ;  the  fingers 
may  also  aid  in  this.  For  this  purpose  also  a  solid  catheter  is  passed 
into  the  bladder.  The  latter  is  drawn  away  from  its  connections, 
and  held  up  by  a  retractor,  or  fixed  in  its  displaced  position  by  a 
few  temporary  catgut  sutures.  It  is  only  by  this  thorough  careful 
separation  of  the  bladder  in  the  first  stage  that  injury  of  it  by  the 
sutures,  or  pressure  upon  it  by  the  uterus,  can  be  avoided,  and,  in 
case  of  pregnancy,  this  allows  of  uterine  expansion  without  dragging 
the  bladder  up.  If  the  uterus  should  not  be  large,  and  if  it  be 
movable,  it  protrudes  from  the  incision  after  the  bladder  has  been 
drawn  up.  It  is  then  easy  to  reach  the  peritoneum  on  the  anterior 
uterine  wall,  and  its  point  of  reflection  upon  the  bladder.  Half  a 
dozen  strong  catgut  sutures  are  next  passed  transversely  in  the 
anterior  uterine  wall,  beginning  at  the  wound  above.  The  points 
of  entrance  and  exit  of  the  stitches  are  2  cm.  apart.     Then  these 

T 


274  DISEASES    OF    WOMEN. 

stitches  are  carried  through  the  edges  of  the  wound  1  cm.  from  the 
margins.  The  sutures  are  not  tied  yet,  but  the  vaginal  wound  is 
closed  with  a  continuous  catgut  suture  from  the  urethra  to  the 
cervix,  Orthmann's  instrument  is  removed,  and  then  the  sutures 
are  tied  in  the  order  of  their  insertion.  The  cervix  is  pushed 
upward  and  back  as  far  as  possible,  and  pressure  applied  from  above 
on  the  fundus  puts  the  uterus  into  an  advanced  position  of  ante- 
version,  in  which  it  is  fixed  by  firm  tamponing  of  the  vagina  with 
iodoform  gauze.  The  bladder  is  freed.  The  patient  is  kept  in  bed 
for  eight  or  ten  days.  The  catheter  is  used  if  necessary  ;  the  gauze 
is  removed,  and  astringent  vaginal  douches  are  given.  >Secondary 
treatment  generally  extends  over  eight  or  ten  days.  Usually  the 
operation  is  easily  performed  without  any  trouble. 

The  advantages  of  this  operation  are :  It  is  performed  in  the 
vault  of  the  vagina ;  it  is  less  dangerous  than  others ;  convalescence 
is  speedy. 

Mackern'odt,  recognizing  the  danger  of  adhesions  which  cause  anteflexion 
from  Diihrsseii's  method  of  fixing  the  uterus  to  the  vagina  outside  the  peri- 
toneum, has  latelj^  performed,  as  we  have  already  stated,  vesico-fixation.  In 
this  operation  there  are  the  dangers  of  peritoneal  heemorrhage,  perforation  of 
the  intestine  or  bladder,  and  last,  though  not  least,  sepsis.  In  many  of  Macken- 
rodt's  cases  of  vagino-fixation,  the  patients  complained  of  bladder  troubles, 
and  at  times  pyosalpinx  resulted.  If  vagino-fixation  be  necessary,  he  operates 
by  separating  the  bladder  from  the  uterus  and  opening  the  abdominal  cavity ; 
the  anterior  flap  of  the  peritoneum  is  stitched  to  the  top  of  the  uterus,  and 
then  the  posterior  surface  of  the  bladder  to  the  front  of  the  uterus,  thus 
closing  the  vesico-uterine  pouch. 

Intraperitoneal  Vaginal  Fixation  (A.  Martin's  method). — 
The  genitals  having  been  shaved,  and  the  thorough  disinfection  of 


Fig.  188.- — A.  Martin's  Perineal  Ketractor.* 

the  vagina  secured,  the  woman  is  brought -well  to  the  edge  of  the 
table,  a  capable  assistant  at  either  side  holding  the  thighs  apart. 
The  operator  sits  in  front,  the  uterus  is  drawn  down,  and  its  length 

*  For  A.  Martin's  large  i^eriueal  retractor,  see  List  of  Appliances. 


UTElthXK    l>  l^J'LA  CL'JI/AW  TS. 


275 


arid  position  are  ascertained  by  tlie  sound.  The  cavity  is  next 
curetted,  and  any  debris  laid  aside  for  examination.  It  is  now 
washed  out  with  a  pipette,  and  a  little  perchloride  of  iron  solution 
is  injected.  Orthmann's  combination  of  uterine  sound  with  claw 
forceps  is  now  taken,  and  the  sound  extremity  having  been  passed 
into  the  uterus,  the  neck  is  seized,  and  the  uterus  is  drawn  down- 


FiG.  189. — Vulcanite  Pipette. 


wards,  so  as  to  place  it  and  the  anterior  cul-de-sac  well  on  the  stretch. 
One  of  the  assistants  seizes  the  vaginal  retractor  below  the  urethra, 
drawing  it  well  up  out  of  the  way,  at  the  same  time  that,  with  the 
same  hand,  he  directs  the  stream  of  aseptic  fluid  from  an  irrigating 
pipette  over  the  parts,  and  this  continues  to  play  through  the  entire 
operation.  The  operator,  thus  fixing  and  stretching  the  uterus  with 
one  hand,  carries  an  incision  directly  in  the  middle  line  through  the 


Fig.  190. — Large  Coxical  Retkactor  uf  Maktix,  to  prutect  the  Bladder. 

mucous  membrane.  (If  it  be  desired  to  do  anterior  colporrhaphy 
at  the  same  time,  the  incision  is  carried  elliptically  at  either  side 
so  as  to  remove  an  oval  portion  of  the  mucous  membrane.)  This  is 
then  reflected  up  with  a  few  strokes  of  a  knife,  and  the  sub-mucous 
tissue  is  cautiously  divided,  the  greater  part  of  the  remainder  of 
this  step   of   the  operation   being   effected  with  finger,  scissors,  or 


276 


DISEASES   OF    WOMEN. 


knife-handle,  or  cautious  dissection  with  scalpel.  The  retractor  is 
carefully  used  to  protect  the  bladder  and  keep  it  out  of  harm's  -way. 
When  the  peritoneum  is  reached  and  divided  with  scissors,  the 
retractor  is  slipped  underneath,  the  uterus  is  seized  higher  up,  and 
gradually  overturned  and  brought  into  the  vagina.  Then  the  ovary 
and  tube  at  either  side  are  sought  for,  seized,  brought  into  view, 


Fig.  191. — Martix's  Needle-holder. 


and  examined.  If  healthy,  they  are  returned,  or  the  ovary,  if  folli- 
cular, may  first  be  stabbed  in  several  places  with  the  point  of  a 
knife  ;  otherwise  the  afiected  adnexa  are  resected  or  removed  in  toto. 
The  uterus  having  been  returned,  the  gut  sutures  are  carried  through 
the  lips  of  the  vaginal  incision,  and  made  to  include  the  uterine  wall 

in  continuous  fashion.  The  peri- 
toneum is  now  closed,  and  likewise 
the  vaginal  opening,  with  continu- 
ous sutures.  Of  course,  if  simple 
colpotomy  alone  be  performed,  the 
uterus  and  appendages  are  re- 
turned, and  only  sufficient  inter- 
ference is  resorted  to  as  the  occasion 
delnands.  The  operation  in  the 
majority  of  cases  where  the  womb 
is  not  fixed  by  adhesions,  or  the 
adnexa  considerably  diseased,  can 
be  rapidly  performed,  the  great 
point  being  that  the  bladder  should 
be  drawn  well  up  out  of  reach,  and 
carefully  guarded  by  the  retractor. 
Amputation  of  the  neck  of  the  uterus  can  be  combined  with  this 
procedure,  the  posterior  lip  being  first  removed,  and  the  flap  sutured 


Fig.  192. — Various- sized  Curved 
Htstereotomt  Needles.* 
.    (A.  Martin's  pattern.) 


*  There  is  a  size  smaller  tliau  that  depicted  in  the  figure. 


UTERINE  DISPLACEMENTS.  277 


with  gut,  the  anterior  being  left  until  the  vagina  has  been  closed, 
when  it  is  also  removed,  and  the  Hap  similarly  sutured  with 
gut/ 

Vineberg's  Operation — Traction  through  the  Round  and   Broad 

Ligaments. 

The  principle  consists  in  making  tracrion  on  the  uterus  by  means  of  the  round 
and  broad  ligaments,  and  not  on  the  uterine  wall,  thus  leaving  the  uterus  free  to 
enlarge  during  pregnancy.  The  patient  is  prepared  as  if  for  vaginal  hysterec- 
tomy. The  cervix  is  drawn  by  a  vulsellum  downward  and  outward  to  the 
vulva.  Another  vidseUum  catches  the  anterior  vaginal  wall  near  the  urethral 
opening  and  is  held  upward.  In  this  manner  the  anterior  vaginal  wall  is  put 
upon  the  stretch,  A  longitudinal  incision  is  now  made  extending  from  the 
mound  just  behind  the  urethral  meatus  to  the  vaginal  attachment  of  the 
cervix.  The  two  flaps  thus  formed  are  separated  fi-om  the  underlying  bladder. 
They  should  be  separated  freely,  and  then  the  utero- vesical  pouch  of  perito- 
neum is  opened.  The  opening  between  the  bladder  and  the  uterus  should 
be  ddated  as  much  as  possible.  The  bladder  is  held  out  of  the  way  by  an 
anterior  vaginal  retractor.  The  anterior  wall  of  the  uterus  is  exposed  and  a 
silk  traction  suture  should  be  passed,  by  which  the  uterus  can  be  pulled  down 
into  the  incision.  If  the  adnexa  must  be  examined  they  can  be  delivered  by 
hooking  two  fingers  over  the  ftmdus  and  drawing  them  forwards.  In  cases 
where  they  need  not  be  dehvered.  and  where  visual  inspection  of  them  is 
unnecessary,  the  two  fingers  are  hooked  behind  one  horn  of  the  uterus  and 
the  coiTesponding  tube  and  round  ligament  are  drawn  well  into  the  incision. 
A  suture  of  silkworm  gut  is  earned  behind  the  round  hgament  about  three  or 
four  centimetres  from  its  insertion  into  the  uterus.  It  is  passed  from  above 
down  and  is  made  to  catch  a  portion  of  the  tissue  immediately  beneath  the 
ligament.  A  second  one  may  be  passed  nearer  to  the  uterus.  The  same  is 
done  on  the  opposite  side.  These  round  ligament  sutures  on  each  side  are 
then  carried  to  the  vaginal  flap,  at  a  point  corresponding  to  the  lateral  sulcus, 
as  near  the  pubic  arch  as  possible.  They  are  tied  loosely  while  the  uterus  is 
held  forward  by  the  traction  sutm-e.  The  peritoneum  is  closed  by  continuous 
catgut  suture  and  the  vaginal  flaps  are  brought  together,  previous  to  which 
the  traction  suture  has  been  removed.  It  may  be  necessary  in  some  cases  to 
apply  an  additional  uterine  fixation  suture. 

*  See  chapter  on  '  Yaginal  Hysterectomy '  for  other  instruments,  as  sclBsors  and 
retractors,  etc..  required  in  colpotomy  :  also  the  operation  of  ccelio-salpingo- 
oophorectomy  for  a  complete  description  of  the  operations  of  anterior  and 
posterior  colpotomy. 


CHAPTER   XIII. 

UTERINE   DISPLACEMENTS   (continued). 

Prolapsus. 

Br  prolapse  of  the  uterus  we  mean  a  descent  of  the  uterus  in  the 
pelvis ;  this  descent  is  attended  by  relaxation  of  the  vaginal  walls, 
prolapse,  and  frequently  inversion  of  the  vagina  itself.  The  bladder 
is  involved  according  to  the  degree  of  the  prolapse.  If  the  uterus 
pass  outside  the  vulva,  we  may  have  an  accompanying  cystocele 
or  rectocele,  both  bladder  and  rectum  being  dragged  on  by  the 
descending  uterus  and  vagina.  The  prolapse  is  divided  into  three 
stages :  in  the  first  the  uterus  lies  entirely  within,  in  the  second  it 
makes  its  appearance  outside,  the  vulva,  and  in  the  third  it  is  pro- 
truded entirely  outside  the  vulvar  orifice.  The  two  latter  stages 
are  also  styled  'procidentia.'  The  influence 
exerted  by  the  uterine  peritoneal  supports, 
the  vagina,  and  perineum,  in  maintaining  the 
uterus  in  its  position  in  the  pelvis  has  been 
already  referred  to.  We  find  four  conditions 
associated  with,  and  contributing  to,  pro- 
lapse :    relaxation   of    the    pelvic    ligaments, 

atonicity  of  the  vaginal  walls,  relaxed  vaginal 

Fig.     193.  —  Showing  .1    .  j  it  i,       j.  • 

.^  outlet,   and   weakened    or   absent   perineum. 

Gradual  Descent  of  -  ^  . 

Uterus.    (Thomas.)       Further    descent    of    the    uterus    necessarily 
means    version.      As    the    heavy    uterus    de- 
scends, the  fundus  yields  to  the  abdominal  pressure,  and  is  directed 
or  forced  backwards.     A  state  of  retroversion  thus  ensues. 

The  displacement  may  commence  with  retroversion  or  anteversion 
of  the  uterus — commonly  the  former ;  or  the  descent  of  the  womb 
may  be  consequent  upon  a  prolapsed  condition  of  the  vagina.  It  is 
rare  to  see  a  well-marked  case  of  prolapse  of- the  uterus  where  there 
is  not  vaginal  prolapse,  which,  in  the  great  majority  of  instances, 
has  occurred  synchronously  with  the  uterine  descent,  the  causes 
which  operate  in  producing  the  one  displacement  at  the  same  time 


VTi:  II /XE   I)  ISr LA  CKMENTS. 


279 


tending  to  induce  the  other.  It  is  frequently  difficult  to  say 
whether  these  causes  have  first  taken  effect  on  the  vagina  or  uterus. 
The  uterus  descends  in  the  vaginal  axis,  and  gradual  inversion  of 
the  vagina  accompanies  its  downward  progress.  The  entire  organ 
becomes  congested,  and,  as  a  consequence,  there  is  hypertrophy  both 
of  the  supra-  and  infra-vaginal  portions,  generally  greater  in  the 
latter,  which  is  thickened  and  elongated.  This  hypertrophic  con- 
dition of  the  entire  cervix  is  an  important  factor  amongst  the  causes 
producing  complete  prolapse. 

If  we  thus  take,  in  their  sequence,  the  usual  pathological  events 
which  operate  during  the  occurrence  and  completion  of  the  prolapsus 
or  procidentia,  they  would  be  much  as  follows:  (1)  Relaxation  of, 


Fig.  19i. — Prolapse  complicated  with  Cystocele.*    (Author.) 

or  deficiency  in,  the  uterine  supports  ;  (2)  retroversion  of  the  uterus  ; 
(.3)  descent  of  the  uterus ;  (4)  partial  prolapse  of  the  vagina ;  (5) 
incipient  inversion  of  the  vagina  ;  (6)  incomplete  prolapse  of  the 
uterus,  with  descent  of  the  bladder,  and  possibly  of  the  rectum  ;  ^  7) 
enlargement  of  the  uterus,  with  hypertrophy  of  the  supra-  and  infra- 
vaginal  portions  of  the  cervix,  and  eversion  of  the  lips  of  the  os 
uteri ;  (8)  further  inversion  of  the  vagina,  with  protrusion  of  its 
anterior  wall,  and  thickening  of  the  mucous  membrane,  which 
gradually  becomes  hard  and  may  be  eroded  in  parts ;  (9)  complete 
prolapse  of  the  entire  uterus  and  inverted  vagina,  both  being  altered 
by  exposure  and  friction. 

*  This  procident  sac  was  reported  upon  by  me  many  years  since.  The  con- 
ditions corresponded  exactly  to  the  section  seen  in  Fig.  196  and  in  Phttes  XVI., 
XVII.,  p,  309. 


280 


DISEASES   OF    WOMEN. 


Causation. — The  common  predisposing  causes  are  :  Pregnancy  ; 
deficient  or  absent  perineum  ;  laceration  of  the  cervix  ;  uterine 
tumours,  abdominal  tumours ;  uterine  hyperplasia ;  impi'udent 
clothing  ;  advancing  age ;  '  too  roomy '  pelvis  ;  constant  standing, 
and  the  raising  of  heavy  weights  ;  accident  or  shock ;  labour,  in 
which  instrumental  delivery  has  been  necessary.  In  older  women 
who  have  borne  many  children  we  occasionally  find  all  the  pelvic 
supports   weakened,  the  ligaments   enlarged,  the  vagina  having  a 


Fig.  195. — Prolapsus  with  Ctstocele.    Fig.  196. — Hypertrophic  Elongation 
(After  Scheceder.)  of  Cervix.     (Schbceder.) 

These  drawings  are  placed  side  by  side  so  that  the  two  conditions,  prolapsus 
and  hypertrophy,  may  be  compared.  See  Plates  XVI.  and  XVII.,  p.  309, 
and  the  diagrammatic  representations  of  the  sections  of  the  jirocident  sacs. 

tendency  to  prolapse,  the  perineum  deficient  in  vital  tone,  and  the 
sphincter- vaginal  muscles  also  enfeebled. 

Laceration  of  the  cervix,  as  a  consequence  of  labour,  has  as  frequent 
attendants  an  enlarged  uterus,  a  relaxed  outlet,  and  a  deficient  perineum. 
Both  uterine  tumours  and  uterine  hyperplasia  cause  increase  of  weight  of  the 
uterus,  and  so  tend  to  prolapse.  Pressure  directed  on  the  uterus  from  above, 
either  from  some  abdominal  tumour,  or  from  the  more  common  sources, 
tight  clothing  and  heavy  garments,  pushes  it  downwards  and  induces  pro- 
lapse.    Great  exertion,  necessitating  fixation  of  the  diaphragm  and  straining 


UTER IXK    n T^r LA  CEMENTF^. 


281 


"^r 


\ 


oftbrts  of  the  abdominal  muscles,  when  continued  for  a  length  of  time  in  some 
laborious  occupation,  causes  general  weakness  of  the  pelvic  ligaments  and  a 
sinking  of  the  uterus.  This,  with  the  secondary  changes  occurring  in  tlie 
uterus  itself,  is  the  cause  of  the  descent. 

During  some  violent  efforts,  as  in  epileptic  convulsions,  while  straining  at 
stool,  or  in  a  severe  fit  of  coughing,  the  uterus  may  descend  and  be  prolapsed. 
Such  an  accident  is  attended 
by  gi'eat  pain,  symptoms  of 
shock,  and  possiblj'^  internal 
haemorrhage.  As  a  rule,  there 
has  been  some  antecedent 
condition,  as  one  of  those 
causes  mentioned. 

It  is  well  to  remember  that 
pregiaancy  has  occurred  in 
cases  of  prolapse,  as  also  a 
tubal  fretation,  a  submucous 
fibroid,  an  intra-uterine  poly- 
pus, or  adnexal  disease. 

Relaxed  Vaginal  Out- 
let.— Howard  Kelly  enters 
fully  into  the  clinical  ap- 
pearances and  treatment 
of  this  condition,  which  is 
so  frequent  an  accompani- 
ment of  cystocele  and  rec- 
tocele,  and  which  may  have 
been  present  prior  to,  and 
independent  of,  any  lacera- 
tion of  the  perineum.  The 
appearances  as  noted  by 
him  are  those  we  are  fa- 
miliar with — a  wide  and 
somewhat  everted  anus,  a 
flattened  and  broad  but- 
tock cleft,  with  the  skin 
surface  of  the  perineum 
unusually  deep,  while  the 
fourchette  is  intact.  On 
the  other  hand,  the  skin 
surface  of  the  perineum 
may  be  torn,  while  the  deeper  structures  have  not  been  involved. 
In  many  of  the  worst  forms  of  relaxation  the  perineum  is  deeper 


\ 


\ 


Fig.  19( 


— IIklaxed  Yagixal  Outlet. 
(Howard  Kelly.) 


282  DISEASES   OF   WOMEN. 

on  the  skin  surface  than  before  childbirth,  a  condition  due  to  the 
overstretching  of  the  external  skin  at  the  time  the  outlet  is  broken 
down.  On  separation  of  the  labia,  there  is  pouting  or  protrusion  of 
one  or  both  of  the  vaginal  walls.  We  can  best  estimate  the  degree 
of  protrusion,  and  associated  descent  of  the  cervix  uteri,  by  exami- 
nation by  the  finger  of  the  latter  while  the  patient  is  standing. 
Examination  of  the  perineum  will  demonstrate  its  relative  thinness, 
and  the  strength  or  displacement  of  the  levator  ani  fibres,  the 
degree  of  relaxation  and  consequent  effect  on  the  pelvic  oi'gans, 
depending  upon  the  degree  of  interference  with,  and  the  disposition 
of  the  fibres  of,  this  muscle.  The  administration  of  an  anaesthetic, 
by  preventing  contraction,  enables  us  to  determine  more  completely 
the  extent  and  degree  of  the  relaxation. 

Symptoms. — Pain  is  felt  of  a  'dragging'  and  'bearing-down' 
nature — mostly  in  the  back  and  loins,  aggravated  by  standing  or 
walking.  The  patient  occasionally  complains  of  a  sensation  as  if 
'  something  were  coming  down,'  when  at  stool.  In  the  earlier  stages 
the  symptoms  of  retroversion  are  present ;  later  on,  when  the 
bladder  and  rectum  participate  in  the  displacement,  vesical  and 
rectal  distress  follow ;  such  distress  is  felt  as  rectal  irritation, 
tenesmus,  sense  of  pressure,  occasional  difficulty  in  deftecation, 
ending,  when  there  is  complete  prolapse,  in  cystocele  or  rectocele. 
The  congestion  which  accompanies  the  prolapse  is  often  the  cause 
of  menorrhagia  or  metrorrhagia.  In  extreme  cases  the  epithelial 
surface  of  the  procident  mass — at  first  thickened  and  rough — may 
inflame  and  ulcerate,  and  these  ulcerations  may  scale  over  and 
occasionally  bleed.  The  irritation  from  the  urine  still  further 
increases  such  ulcerations.  I  have  seen  a  large  gangrenous  slough 
on  the  surface  of  a  procident  uterus.  This  may  be  the  result  of 
strangulation  of  the  mass  at  the  vulvar  opening. 

Diagnosis. — In  the  earlier  stages  of  prolapsus  the  os  uteri  is  felt 
lower  than  usual,  and  the  body  of  the  womb  deeper  in  the  pelvis. 
The  uterus  may  be  anteflexed,  or  there  may  have  been  an  ante- 
cedent retroversion.  Even  in  this  early  stage  we  may  detect 
incipient  prolapse  of  the  vagina  and  a  flaccid  condition  of  the 
anterior  vaginal  wall.  If  the  uterus  have  descended  for  any  dis- 
tance, if  it  present  at  the  vulva,  or  outside  it,  the  least  care  will 
prevent  any  error  of  diagnosis.  It  is  better  to  examine  the  patient 
standing,  when  we  desire  to  estimate  the  degree  to  which  the  uterus 
has  descended.  It  is  well  always  to  measure  the  uterine  cavity 
with  the  sound.     This   is   necessary,   not   alone  to    determine   the 


UTEETNE  DT.^riACEMENT!^. 


283 


position  of  the  uterus,  but  also  to  differentiate  true  prolapse  of  the 
uterus  from  pi-olapse  complicated  with  elongation. 

In  ordinary  i)rolap.se  the  sound  may  pass  a  little  further  than 
natural  into  the  uterus,  or  the  canal  may  be  normal  in  length  ; 
while  if  there  be  hypertrophic  elongation  of  the  cervix,  the  sound 
passes  a  considerable  distance,  proving  that  the  uterine  cavity  is 
enlarged,  while  by  palpation  we  feel  the  fundus  in  its  proper  position. 
If  we  pass  the  uterine  sound  into  the  prolapsed  uterus,  while  in  the 
state  of  procidentia,  it  may  enter  to  the  extent  of  some  three  or 
more  inches.  When  the  strain  is  removed  from  the  relaxed  tissues 
by  reposition,  it  will  be  found  to  pass  to  about  the  usual  length, 
With  any  exercise  of  caution,  no  one  can  mistake  a  case  of  proci- 
dentia for  polypus  or  inversion  of  the  womb.  (See  '  Hypertrophic 
Elongation  of  Cervix.') 

Treatment. — We  may  divide  the  treatment  of  prolapsus  thus  : 
(1)  prophylactic;  (2)  replacement;  (3)  retention:  (4)  operation. 
Under  the  first  class  we  include  those 
general  constitutional  and  local  mea- 
sures which  tend  to  reduce  the  size 
and  weight  of  the  uterus.  With  this 
object  we  enjoin  rest  if  the  patient's 
circumstances  will  permit.  Unfor- 
tunately, many  cases  of  prolapse  are 
met  with  in  women  who  have  to  work 
for  their  living,  and  who  cannot 
afford  to  rest.  In  the  earlier  stages, 
when  we  recognize  the  displacement, 
there  should  be  free  use  of  the  vaginal 
douche,  with  astringent  washes,  such 
as  those  of  alum,  tannin,  or  sulphate 
of  zinc,  or  tampons  of  salicylic  acid 
wool  and  glycerine.  The  tampon  can 
be  introduced  by  the  patient  at  bed- 
time, and  worn  during  the  night. 
When  the  vagina  is  tamponed  by  the 
surgeon,  the  patient  should  be  placed  in  the  knee-elbow  posture. 
Tight-lacing  must  be  prohibited,  and  the  undergarments  suspended 
from  the  shoulders,  and  not  from  the  hip.  The  patient  may  be 
made  to  wear  a  properly  adjusted  abdominal  support  or  belt.  This 
should  fit  accurately,  raising  and  supporting  the  intestines  above 
the  pubes. 


Fig.  198. — Kuptueed  Perineum, 
Eectocele,  and  Ctstocele 
WITH  Elongation  of  Cervix, 
simulating  prolapsus. 
(After  Martin.) 


284 


DISEASES   OF   WOMEN. 


A  silk-elastic  support^  made  like  a  weft  Nightingale  cholera  belt,  is  very 
comfortable,  and  will  be  found  useful  in  many  cases  where  our  object  is  to 
keep  the  abdomen  warm.     They  can  also  be  had  in  Jaeger's  flannel. 

Regular  cold  bathing,  and  especially  sea-bathing,  is  of  service. 
Any  constitutional  or  local  condition  which  either  promotes  con- 
gestion of  the  uterus  or  favours  relaxation  of  its  supports,  must  be 
attended  to.  Occasional  depletion  of  the  cervix  •  the  administration 
(especially  during  the  menopause)  of  such  tonics  as  strychnine  and  the 
mineral  acids,  quinine  and  ai-senic  ;  careful  attention  to  the  bowels,  so 
as  to  prevent  all  straining  at  stool,  the  occasional  use  of  a  cold-water 
enema,  and  the  correction  of  any  version  or  flexion  of  the  womb,  are 
some  of  the  simplest  and  most  eflicacious  measures  we  can  adopt. 

It  is  of  special  importance  to  attend  to  any  chronic  cough,  and  to 
allay  laryngeal  and  lung  irritation.     If   the  prolapse  should  have 


Fig.  199. — Zwancke's  Pessary 
(open). 


Fig.    200.  —  Schultze's     Figuee-of- 
EiGHT    Pessary,    moulded    from 
Celluloid  Eing,  foe  Retroversion 
-     AND  Prolapse. 


lasted  for  some  time,  and  the  uterus  protrude  from  the  vulva,  we 
have  to  replace  it. 

To  replace  the  procident  mass,  we  get  the  j)atient  into  the  knee- 
elbow  position,  and,  grasping  the  base  of  the  tumour,  we  return  that 
portion  last  which  protruded  first.  The  uterus  can,  if  necessary,  be 
prepared  for  the  use  of  a  pessary,  and  those  means  already  detailed 
should  be  employed  to  contract  the  vagina  and  reduce  uterine 
congestion. 

To  retain  the  uterus  in  position  we  have  recourse  to  pessaries.  We 
may  classify  those  useful  in  prolapse  under  these  heads  : — ■ 


UTERTNE  DISPLACEMENTS. 


285 


(a)  Those  suitable  in  incipient  descent,  complicated  with  retro- 
version or  anteflexion. 

(h)  Those  applicable  in  incomplete  prolapse  of  the  uterus,  with 
partial  prolapse  of  the  vagina. 

(c)  Those  suitable  for  complete  prolapse  of  the  utei'us,  with 
in\ersiou  of  the  vagina  and  loss  of  contractility  of  the 
vaginal  walls. 

For  class  (a)  the  best  pessary  we  can  employ  is  the  ordinary 
Hodge.     AVe  may  select  any  material  we  choose — vulcanite,  cellu- 


FiG.  201. — Napier's  Prolapse  Pessary.       Fig.  202. — Braun's  Colpeubynter. 

loid,  or  wire  with  rubber  covering.  The  celluloid  is  preferable,  as 
it  is  the  easiest  moulded  to  the  shape  and  size  we  require  ;  we  should 
always  mould  the  shape  and  size.  We  adapt  it  according  as  the 
uterus  is  retroverted  or  anteflexed.  Galabin's  pessary  is  an  admir- 
able support  in  those  cases  of  descent  complicated  with  anteflexion. 
Schultze's  figure-of-8  pessary,  moulded  from  the  celluloid  ring,  is 
also  useful. 

In  class  (b)  Hodge's  pessary  will  also  be  found  to  answer  in  a 
large  number  of  cases.  Here  the  pessary  should  be  well  cupped, 
large  enough  to  retain  its  position,  but  not  of  such  a  size  as  to 
forcibly  distend  the  vagina.  All  pessaries  should  be  periodically 
removed  and  cleansed,  and  during  their  use,  vaginal  deodorant  and 
antiseptic  injections  should  be  occasionally  employed  ;  or  we  may  try 
the  rubber  glycerine  ring  (Arnold) — it  is  by  far  the  best  soft  ring 
pessary  made.  It  has  the  disadvantage  of  requii-ing  more  frequent 
renewal.  The  ring  must  be  of  a  size  suitable  to  the  case,  sufliciently 
thick,  and  with  a  strong  spring.  In  the  third  degree  of  prolapse, 
if  a   patient  ivill  not  submit  to  operation,   we  may  have   to   use   a 


286  DISEASES   OF    WOMEN. 


Zwancke's  pessary,  of  the  vulcanite  kind,  or  the  wire  modification 
of  Clement  Godson. 

Many  patients  manage  the  vulcanite  Zvvancke  best,  and  prefer  it  to  the 
wire.  It  has  the  disadvantage  that  it  is  apt  to  accumulate  discharge,  and 
thus  become  unpleasant;  also  the  screw  which  regulates  the  divergence 
of  the  wings  is  liable  to  be  broken  in  screwing  or  unscrewing  it.  The  patient 
should  be  taught  how  to  insert  or  remove  it.  This  latter  she  should  do 
hefore  lying  down  at  night,  placing  the  pessary  in  a  disinfectant  solution. 
Godson's  is  equally  easy  of  adjustment,  and  it  certainly  has  the  advantage  of 
greater  cleanliness  and  durability. 

In  complete  procidentia  it  will  be  found  extremely  difficult  to 
sustain  the  uterus  by  any  pessary.  I  dislike  the  principle  of  all 
pessaries.  In  some  cases,  material  support  and  considerable  comfort 
may  be  obtained  from  a  carefully  fitted  abdominal  support,  to  which 
is  attached  a  perineal  pad.  In  most  cases  of  procidentia  operation 
is  the  only  proper  course  to  advise. 

Elongated  Cervix,  Complicating  Prolapse  of  the  Uterus  or 
Vagina. — I  do  not  intend  to  enter  into  the  various  matters  in  dis- 
pute regarding  the  relation  of  the  hypertrophic  elongation  of  the 
cervix  uteri  to  prolapse  of  the  uterus  or  vagina.  I  shall  limit  any 
observations  to  such  practical  points  in  the  etiology  and  diagnosis 
of  the  afiection  as  are  requisite  for  every  student  and  practitioner 
to  know.  The  following  facts,  which  are  now  generally  accepted, 
have  a  practical  bearing  on.  the  management  of  this  condition : — 

Causation, — 1.  The  cervix  uteri  may  be  hypertrophied  and  lengthened  out 
either  in  its  infra- vaginal  or  supra-vaginal  portions.  Whether  this  elongation 
be  a  primary  growth  (Huguier),  independent  of  any  dragging  action  of  the  pro- 
lapsing vagina  and  bladder,  or  a  consequence  of  this  latter,  is  a  matter  of 
dispute.  J.  Taylor  considers  that  it  is  the  result  of  non-involution  of  the 
uterus  after  labour,  when  the  uneffaced  infra-vaginal  cervix  drags  on  the  non- 
glandular  isthmus  and  draws  it  out.  He  does  not  believe  in  the  commonly 
accepted  doctrine  of  the  effacement  of  the  glandular  cervix  during  pregnancy, 
and  is  of  opinion  that  it  is  simply  hypertrophied  and  temporarily  expanded. 

2.  Elongation  of  the  infra-vaginal  portion  of  the  cervix  is  not,  as  a  rule, 
attended  with  prolapse.  The  fundus  remains  at  its  proper  level  in  the  pelvis, 
nor  does  the  os  descend  so  far  as  to  protrude.  There  is  a  peculiar  elongation 
of  the  anterior  lip  accompanyiny  this  condition,  known  as  '  tapiroid.' 

3.  Hypertrophic  elongation  of  the  supra- vaginal  portion  is,  sooner  or  later, 
associated  with  prolapse  and  procidentia  of  the  uterus  and  bladder.  There 
are  here  two  principal  factors — growth  and  traction  :  which  is  the  initial 
process  it  is  difficult  to  say.  It  would  seem  that  each  has  an  independent 
share  in  the  early  stages  of  the  distortion.  It  is  difficult  to  define  the  exact 
spot  where  the  '  vicious  circle  '  commences. 


UTERINE   ni.^ PLACEMENTS.  287 


4.  Eversion  of  the  lips  of  the  os  uteri,  with  exposure  of  the  cervical  canal, 
and  laceration  of  the  cervix,  are  common  attendants  on  this  form  of  prolapse 
of  the  womb. 

The  most  frequent  complications  of  hypertrophic  elongation  of 
the  cervix  are  :  faulty  involution  of  the  uterus  after  labour ;  and 
laceration  of  the  cervix  during  labour  (in  these  latter  conditions  we 
tind  the  two  associated  states  which  usually  produce  hypertrophic 
change,  viz.,  hypertemia  and  hyperplasia) ;  fibroid  tumours ;  pelvic 
adhesions  ;  uterine  displacements  ;  laborious  occupations. 

Various  Views  on  the  Operative  Treatment  of  Procidentia  and 
Prolapse  of  the  Uterus. — Were  the  treatment,  prophylactic  and 
palliative,  for  prolapsus  uteri  undertaken  during  its  earlier  stages, 
and  were  such  conditions  as  retroflexion,  hyperplasia  of  the  uterus, 
incipient  rectocele  or  cystocele,  deficiency  of  perineum,  and  relaxed 
vaginal  outlet,  early  recognized  and  dealt  with,  there  would  be  no 
necessity  for  many  of  the  extreme  measures  which  are  called  for  by 
the  more  advanced  and  graver  forms  of  the  affection.  The  opera- 
tions, which  in  the  great  majority  of  cases  are  sufficient  to  cure  the 
milder  types  of  prolapse,  are  perineorrhaphy,  various  forms  of  col- 
porrhaphy,  and  rectification  of  a  relaxed  outlet.  In  more  advanced 
stages  we  may  ha"\"e  to  add  to  these  amputation  of  the  cervix  uteri, 
ventro-fixation,  or  an  Alexander- Adams  operation,  with  more  exten- 
sive denudations  for  either  rectocele  or  cystocele,  and  attachment 
of  the  bladder  ;  later  still,  in  the  most  aggravated  forms,  shorten- 
ing of  the  utero-sacral  ligaments,  or,  as  I  should  personally  prefer, 
hysterectomy  with  pai'tial  ablation  of  the  vagina,  or,  as  others 
advise,  the  alternative  of  its  complete  extirpation. 

In  the  discussion  on  a  paper  by  Kuestner,*  who  advocated  contraction  of 
the  lumen  of  the  vaginal  canal,  ventral  fixation  and  colporrhaphy,  fixation  of 
the  uterus  to  the  posterior  pelvic  wall,  and,  in  isolated  cases,  pan-hysterec- 
tomy, A.  Martin  argued  that  it  was  not  enough  to  perform  extensive  colpor- 
raphies,  but  that  the  uterus  and  the  whole  pelvic  connective  tissue  should  be 
included  in  the  plan  of  operation.  In  displacement  of  the  bladder,  a  new 
system  of  support  should  be  secured,  either  by  gathering  up  its  base,  vesical 
fixation,  or  retro-fixation.  Removal  of  the  uterus  was  indicated  when  it  was 
so  diseased  that  this  step  must  be  taken  even  were  it  in  its  normal  position. 
As  a  dernier  ressort  extirpation  of  the  entire  procident  mass  might  be  justi- 
fied. Total  extirpation  of  the  uterus  and  vagina  was  indicated  in  many 
cases  ;  he  had  performed  it  ui  nineteen  out  of  two  thousand.  Schauta  makes 
a  longitudinal  incision  in  the  anterior  vaginal  wall,  which  is  undermined,  and 
the  bladder  pushed  upwards.     The  uterus  is  brought  fonvard  out  of  the 

*  Congress  Germ.  Gyn.  Soc.,  1903;  Zentralh.  f.  Gyn.,  Xo.  27. 


288  DISEASES   OF   WOMEN. 


peritoneal  cavity,  and  fixed  into  the  vesico-vaginal  septum,  the  vagina  being 
closed  behind  the  uterus.  Thus  cystocele  is  prevented,  and  the  vagina  com- 
pletely closed.  Bumm  (Halle)  performs  total  extirpation  more  frequently,  as 
it  is  an  absolute  cure.  This  refers  to  patients  at  or  after  the  menopause. 
Doederlein  supports  the  same  view.  Crobak  practises  ventro-fixation  and 
vaginal  shortening  of  the  round  ligaments.  Total  extirpation  was  only 
justifiable  after  the  child-bearing  age.  Freimd  advocates  colporraphy,  ventro- 
fixation, and,  in  cases  of  extreme  prolapse,  panhysterectomy,  at  or  after  the 
menopause. 

Edebolils  inclines,  as  also  does  Christopher  Martin,  who  first  performed  the 
operation  in  England,  to  complete  extirpation  of  the  vagina  in  these  extreme 
cases. 

'  If  we  ever  intend,'  as  Gaillard  Thomas  insists,  '  to  inculcate,  true,  rational, 
and  reliable  precepts,'  we  must  regard  the  perineal  body  as  the  triangular 
concavo-convex  body,  with  its  apex  superioi'ly,  composed  of  strong  elastic 
connective  tissue,  that  fills  in  the  space  between  the  anterior  wall  of  the 
rectum  posteriorly,  tlie  vaginal  wall  anteriorly,  and  the  summit  of  the  vagina 
above.  This  elastic  connecting  pillar  is  itself  under  the  influence  of,  and  is 
supported  on,  muscles,  the  tendencj^  of  whose  action  is  to  throw  the  perineal 
pillar  upwards  and  forwards,  thus  assisting  in  the  support  and  closure  oi  the 
vaginal  canal.  Together  with  it  these  muscles  (1)  sustain  the  anterior  wall 
of  the  rectum,  and  prevent  a  prolapse  of  the  bowel,  which,  did  it  occur,  would 
inevitably  drag  downwards  the  upper  vaginal  concavity,  and  with  it  the 
cervix  uteri,  and  destroy  the  equilibrium  of  the  uterus.  (2)  They  support 
the  posterior  vaginal  wall,  and  prevent  a  prolapse  of  this  partition,  which 
would  favour  rectocele.  (3)  Upon  the  posterior  vaginal  wall  rests  the 
anterior,  and  upon  this  the  bladder,  and  against  the  bladder  lies  the  uterus — 
all  of  which  depend  in  great,  degree  for  support  upon  the  entire  perineal 
body.  (4)  They  preserve  a  proper  line  of  projection  of  the  contents  of  the 
bladder  and  rectum,  and  so  prevent  the  occurrence  of  tenesmus,  a  frequent 
cause  of  pelvic  displacements.  Thus  the  entire  perineal  structure  may  be 
truly  said  to  form  "  the  keystone  of  the  arch  "  on  which  the  uterus  is  sup- 
ported in  the  pelvis.'  *  The  part  played  by  the  utero-sacral  folds  has  been 
already  discussed. 

Some  Operative  Procedures  for  Prolapse  of  the  Uterus  and  Vagina. 


Deferred  closure  of  perineum. 

Tait's  operation  for  laceration  of 
the  perineum. 

Doleris'  modification  of  same. 

Diihrssen's  operation. 

Lateral,  anterior,  and  posterior 
colporrhaphy. 

Sims'  operation. 


Doleris'  operation. 

Eeamy's  operation. 

Colpoperineorrhaphy  (Martin's 
operation). 

Amputation  of  the  cervix,  by 
Sims',  Schroeder's,  and  Martin's 
methods. 

Ventro-fixation. 


*  I  have  here  modified  the  early  teaching  of  Gaillard  Thomas,  in  which  I 
consider  sufiQcient  stress  was  not  laid  on  the  part  played  by  the  perineal  muscles 
in  the  pelvic  floor,  or  the  utero-sacral  ligaments. 


UTER FNE    />  L^PL .  I  CEMENTS. 


289 


Alexander-Adams'  operation.  Panhysterectomy   with   colporrha- 

Colporrhapliy  with   either  ventru-      phy. 
lixation  or  Alexander-Adams.  Operations     on     the     ntero-sacral 

Colpo-hysteropexy  (Sanger's  ope-      ligaments, 
ration).  Extirpation  of  the  vagina. 

Colpectomy  (Miiller). 

We  need  feel  no  snrprise  when,  in  consequence  of  laceration  during  partu- 
rition, or  from  atonic  states  due  to  prolonged  pressure  or  constitutional 
debility,  the  perineal  body  no  longer  performs  its  part  in  the  mechanism 
of  the  pelvic  supports.  Displacements  of  the  uterus  are  amongst  the  conse- 
quences, and  especially  prolapsus.  Assuredly  if  surgeons  only  recognized  the 
ills,  immediate  and  remote,  which  follow  lacerated  perineum,  we  should  less 
frequently  hear  of  '  secondary  operations.'  The  sensible  obstetrician  stitches 
the  perineum  at  once  when  he  recognizes  the  laceration  after  parturition.  The 
futile  plan  of  binding  the  knees  together  were  better  never  conceived,  unless, 
indeed,  for  adoption  after  the  immediate  operation.  It  encourages  procras- 
tination, and  is  almost  certain  to  end  in  failure. 

Take  it  all  in  all,  I  believe  that  there  is  not,  in  the  entire  range  of  gynaeco- 
logical practice,  a  point  more  necessary  to  insist  on  than  early  closure  of  the 
perineal  v/ound  after  parturition.  This  caution  pertains  rather  to  midwifery 
than  to  gynEBCology ;  but  it  has  such  important  bearing  on  the  future  happi- 
ness and  comfort  of  a  woman,  when  the  labour  has  been  long  forgotten,  that 
it  warrants  this  stress  being  laid  upon  it. 

"Whatever  oj)eration  be  performed  (I  believe  that  of  Lawson  Tait 
to   be  one   of   the  most  perfect   in  principle,   and    not   difficult  of 


Fig.  203. — Absent  Perineum  with  Retro- 
VERSiox.     (After  A.  Martix.) 


Fig.  204. — Eoptured    Perineum 
AND  Cystocele.  (Apter  A.  IMartin.) 


execution),  the  objects  are  to  denude  the  edges  of  the  rent ;  to 
expose,  posteriorly,  two  raw  vaginal  surfaces  for  union,  so  as  to 
bring  the  rectum  forward ;  to  restore  the  action  of  the  sphincter 

u 


290  DISEASES   OF   WOMEN. 


and  levator  ani  muscles ;  and  to  create,  when  necessary,  a  new 
perineum.  The  steps  vary  according  as  the  operation  is  intended 
merely  to  rectify  a  partial  or  complete  rupture.  In  the  former 
case,  the  operation  is  a  comparatively  trivial  one,  whereas  in  the 
latter  we  have  not  alone  to  construct  a  perineal  body  and  narrow 
the  vagina,  but  also  to  re-establish  the  functions  of  the  sphincter 
muscle. 

Deferred  Operation  for  Lacerated  Perineum. 

Appliances  required.* — A  straight  scalpel ;  a  pair  of  curved 
scissors ;  artery  forceps,  dissecting  forceps,  some  vai'ious  haemostatic 
forceps ;  well  curved  needles  of  different  sizes ;  needle-holder ; 
cumol-chromic  and  silkworm  gut ;  a  self-retaining  catheter ;  a  few 
vaginal  retractors  ;  some  perineal  hooks  ;  leg  supports  (should  a 
suitable  table  not  be  at  hand).  Two  assistants,  one  nurse  (it  is 
well  to  have  a  second  if  possible),  and  an  anaesthetist  are  always 
i"equired. 

In  all  vaginal  operations  the  usual  aseptic  precautions  are  taken  before  the 
patient  is  placed  on  the  table,  and  the  hair  of  the  vulva,  and  that  in  the  vicinity 
of  the  perineal  wound,  is  carefully  shaved.  Mere  cutting  off  of  the  hair  with 
scissors  at  the  time  of  the  operation  is  not  sufficient.  It  is  better  to  commence 
the  disinfection  of  the  vagina  the  day  before  {vide  chapter  on  Asepsis).  The 
bowel  also  ought  to  be  well  emptied  by  an  aperient  and  enema. 

The  patient  is  placed  opposite  a  good  light,  and  in  the  lithotomy 
position,  the  buttocks  being  brought  well  to  the  edge  of  the  operat- 
ing table.  Should  this  not  be 
provided  with  the  ordinary  leg 
supports,  each  knee  of  the 
patient  is  held  apart  by  an 
assistant,  who  controls  it  with 

his   arm,   while   at   the   same 
Fig.  205. — Self-eetainixg  Catheter.       . .         ,       ,  .    . ,      ,  ,  . 

,a  m  N  time  he  draws  out  the  labium 

(Skene-Goodman.) 

of  that  side  with  a  hook  or 
small  blunt  rake.  As  the  operation  may  be  tedious,  the  feet  and 
legs  of  the  patient  should  be  protected  from  the  cold  by  domette 
bandages  carried  as  far  as  the  knees.  The  surgeon  next  introduces 
two  fingers  of  the  left  hand  into  the  rectum,  and  puts  the  mucous 
membrane   on   the   stretch.      [I   include  here    the    steps   required 

*  The  various  needles,  needle-holders,  scissors,  and  other  appliances  required 
for  all  these  plastic  operations  on  the  vagina  and  associated  operations  on  the 
cervix,  are  all  shown  in  the  test. 


rrr.inxK  displacf.mhsts.  201 


presuming  the  rent  to  extend  as  far  as  the  anus.]  The  operation 
is  commenced  by  paring  oft"  with  knife,  or  scissors,  or  both,  the 
rectal  margin  of  the  mucous  memlji-ane,  and  continuing  the  dis- 
section by  removal  of  a  layer  of  the  mucous  lining  of  the  posterior 
wall  of  the  vagina  to  the  extent  of  an  inch  and  a  half.  The 
lateral  margins  are  now  attacked  in  a  similar  mamier,  until  a 
triangular  raw  surface  at  either  side  of  the  labium  is  exposed,  of 
about  one  inch  in  breadth,  and  over  an  inch  and  a  half  in  length. 
Bleeding  is  readily  controlled  by  haemostatic  forceps  or  Zweifel's 
miniature  angiotribe,  and  the  use  of  very  hot  water.  The  raw 
surface  at  one  side  should  be  an  exact  counterpart  of  that  on  the 
other.  The  extent  of  the  denudation,  anteriorly  and  posteriorly, 
will  depend  on  that  of  the  laceration.  The  surgeon  now  prepares 
to  pass  the  sutures.  A  sharply  curved  needle,  held  in  a  needle- 
holder,  armed  with  a  thread  of  silver  wire,  kangaroo  or  silkworm 
gut,  is  passed  from  the  lower  margin,  and  half  an  inch  to  the  outer 
margin  of  the  anus,  deeply  upwards,  across  the  recto-vaginal  septum, 
well  in  front  of  and  above  the  bowel  orifice,  and  is  brought  with  a 
sweep  of  the  needle  down  and  out,  at  a  corresponding  point  at  the 
opposite  side.  This  is  Emmet's  suture.  When  passed  nothing  should 
be  seen  of  the  thread  save  the  two  ends.  This  suture  is  next  secured. 
The  perineum  is  now  closed  by  sutvires.  The  safest  plan  is  to  pass 
the  first  few  unexposed,  through  the  recto- vaginal  septum.  The  last 
few  passed  will  be  partly  exjaosed  on  the  vaginal  side  of  the  rent. 
Some  operators  prefer  to  secure  the  suture  with  perforated  shot. 
The  wound  is  cleaned  and  sponged  ;  the  thighs  are  brought  together, 
the  patient  is  placed  on  her  back,  and  the  urine  is  drawn  off  every 
six  hours.  [J  much  ])refer  to  draw  off  the  urine  rather  than  trust  to  a 
retained  catheter.  Unless  with  a  very  careful  and  experienced  nurse, 
self- retaining  catheters  are  dangerous  ;  they  are  apt  to  slip  out  and 
endanger  the  success  of  the  operation.  A  short-winged  rubber  female 
catheter,  with  a  tube  attached,  is  simple  and  safe  ;  the  tube  is  closed 
by  a  small  clip.]  The  bowels  may  at  first  be  locked  with  opium,  and 
simple  but  nourishing  food  given.  They  need  not  be  moved  until 
the  sixth  or  seventh  day.  This  may  be  efiected  by  first  filling  the 
rectum  with  olive  oil,  this  being  followed,  after  an  interval,  by  an 
injection  of  olive  oil  with  soap  and  water ;  after  this  has  acted,  the 
rectal  stitch  may  be  removed.  The  patient  must  keep  her  bed  for 
a  fortnight,  and  it  is  well  to  have  the  knees  bound  together.  I 
have  had  equally  good  results  by  the  administration,  every  other 
day,  of  an  olive-oil  enema.     In  fact,  it  is  the  plan  that  I  generally 


292 


DISEASES   OF    WOMEN. 


adopt.  We  get  rid  of  the  unpleasant  complication  of  the  locked 
bowel,  and  the  risk  attendant  upon  the  passing  of  hard  fsecal  masses, 
with  the  consequent  rectal  irritation.  Perfect  cleanliness  must  be 
enforced  after  the  operation,  and  the  vagina  should  be  carefully 
washed  out  each  day  with  tepid  permanganate  of  potash  solution. 
It  is  well  to  keep  a  dry  thymol  pad  over  the  wound,  with  a  light 
perineal  bandage. 

Tait's  Operation. — I  am  indebted  to  the  late  distinguished  gynse- 


FiG.  206.— Splitting  the  Recto-  Fig.  207.— Passage  of  the 

Vaginal  Septum.  Suture. 

These  three  drawings  (Figs.  206,  207,  208)  were  made  for  Fancourt  Barnes  by 
Professor  Vulliet,  of  Geneva. 

cologist  for  the  following  description  of  his  operations,   which   he 
kindly  wrote  for  a  previous  edition  of  this  work. 

*  The  operations  are  of  two  kinds.  The  first  I  term  extension  of  the  peri- 
neum from  behind  forwards,  and  for  this  I  make,  by  means  of  a  sharp  pair  of 
pointed  scissors,  a  horseshoe  incision  round' the  perineum,  the  horns  extending 


1 '  77.7,'  INE    D  ISP  L  A  CEMKXTS. 


•2!):5 


as  far  forwards  as  I  judge  to  be  necessary.  It  is  made  deeply  into  the 
substance  of  tlie  labia  on  each  side,  and  when  its  Haps  are  separated  it  makes 
a  V-shaped  groove  on  each  side.  As  many  silkworm-gut  sutures  as  seem 
necessary — generally  three  or  four — are  inserted  by  a  handled  needle,  the 
needle  entering  well  within  the  margin  of  the  wound,  so  as  to  open  out  the 
V  completely  and  evert  its  lips.  The  outer  flaps  of  each  V  on  the  several 
sides  are  turned  outwards,  and  the  iinier  turned  correspondingly  inwards ; 
and  when  the  stitches  are  tightened  they  are  in  this  way  approximated  as 
plane  surfaces,  and  so  they  unite, 
making  a  very  tirm  and  thick  plat- 
form for  the  displaced  organs  to  rest 
upon,  and  this  rarely  gives  way.  I 
generallj''  now  leave  the  sutures  in 
for  three  or  four  weeks. 

'  For  torn  periueum  the  operation 
again  is  the  same  in  principle,  though 
difterent  in  detail.  When  the  margi- 
nal folds  of  the  buttocks  are  fully 
drawn  asunder  in  such  a  case,  the  old 
tear  is  displayed  by  a  thin  white  line 
of  cicatrix  extending  transversely  to 
the  axis  of  the  rent;  which  of  course 
was  at  right  angles  to  the  plane  of 
the  perineum.  The  healing  of  the 
tear  has  taken  another  direction 
altogether,  and  we  have  the  cicatrix 
at  right  angles  to  the  wound.  This 
is,  so  far  as  I  can  think  out  the 
question  or  know  the  facts,  wholly 
unique  in  its  occurrence.     It  forms 

the  basis  of  the  principle  of  the  operation  which  I  perform,  and  that  is 
absolutely  the  opposite  of  the  principle  of  all  denuding  operations. 
scJieme  of  my  operation  is  to  restore 
the  old  rent  and  unite  it  at  right 
angles  to  its  representative  cicatrix, 
that  is,  at  right  angles  to  the  plane 
of  the  perineum.  In  this  way,  and 
in  this  way  onl}'',  can  the  perineum 
be  truly  restored,  and  from  this 
operation  alone  can  it  be  hoped  that 
the  restoration  will  stand  the  attacks 
of  subsequent  labours,  as  a  large 
number  of  my  restorations  have 
done.  I  do  not  know  one  having 
been  torn  a  second  time. 

'  Having  the  folds  of  the  buttocks  pulled  firmly  apart,  so  that  the  cicatrix 
is  put  on  the  stretch,  I  enter  the  point  at  its  extreme  edge  on  one  side,  and, 
keeping  strictly  to  its  line.  I  run  through  to  its  other  extremity.    The  incision 


Fig.  208. — Wouxd  closed. 


The 


Fig.  209. — D  to  E,  rectal  incisions;  F 
to  C,  vulvar  incisious  ;  D  to  D  marks 
the  line  joining  the  vulvar  and  anal 
rents. 


294 


DISEASES   OF    WOMEN. 


is  about  tbree-eightlis  of  an  inch  deep,  and  it  forms  two  flaps,  a  rectal  and  a 
vaginal.  From  each  end  of  the  incision  it  is  carried  forward  into  the  tissue 
of  each  labia  for  about  an  inch,  and  again  backwards  for  about  a  third  of  an 
inch,  making  a  wound  like  this — ■ 

'  The  vaginal  flap  A  is  held  upwards  (the  patient  being  on  her  back),  and 

the  rectal  flap  B  being  turned  down- 


wards, the  angles  AFC  being  pulled 
by  forceps  diagonally  upwards  and  in- 
wards towards  the  middle  line,  and  the 
angles  B  D  E  being  pulled  downwards 
and  inwards.  The  line  C  E  thus  be- 
comes straight,  and  the  wound  takes 
the  foi'm  shown  in  Fig.  210. 

'  By  means  of  a  stout-handled  and 
well-curved  needle  the  silkworm-gut 
sutures  are  entered  on  one 
side  about  an  eighth  of  an 
inch  within  the  margin  of 
the  wound  (so  as  not  to 
include  the  skin)  at  the 
dots  A.  They  are  buried 
deeply  in  the  tissue  as  far 
as  B,  and  then  the  needle 
is  made  to  emerge  so  as  to 
miss  the  angle  of  the  wound. 
The  needle  again  enters 
at  the  large  dots  C  and 
emerges  at  the  dots  D.  By 
thus  missing  the  upper  or 
deep  angle  of  the  wound 
between  B  and  C,  the  two 
great  and  divided  masses 
of  the  old  perineum,  which 
lie  in  the  parallelograms  re- 
spectively bounded  by  the 
lines  of  large  dots  A — B 
and  C — D,  are  accurately 
adapted.  The  rectal  and 
vaginal  flaps  respectively 
point  into  the  rectum  and 
vagina,  and,  like  an  old- 
fashioned  flap  -  valve,  pre- 
vent noxious  material  enter- 
ing the  wound.  The  result- 
ing mass  of  perineum  is 
amazingly  large ;  union  is 
almost  inevitable,  for  I  have  failed  only  twice  in  many  hundreds  of  cases,  and 


Fig.  211.*  —  Doleris'  Modification  of  Tait's 
Operation.  Eaising  up  the  Semilunar  Fold, 
and  introdl'ction  op  the  sctuees.  (bonnet 
AND  Petit.) 

The  vaginal  flap  is  resected  above  the  line  of  the 
suture  shown  ia  the  drawing,  and  thus  the 
closure  of  the  vaginal  denuded  surface,  and 
the  remaining  portion  of  the  raised  tongue  of 
mucous  membrane,  is  secured. 


*  See  also  page  298. 


UTERI. \E   niSI'LAGEMENT.^.  '^95 


then  becaiise  there  had  been  previous  denuding  o[)cratioiis.  Tlic  resulting 
cicati'ix  is  absolutely  linear,  and  so  resembles  the  natural  raphe,  that  in  three 
or  lour  months  after  the  operation  it  is  quite  impossible  to  determine,  from 
the  appearance  of  the  parts,  that  the  perineum  has  ever  been  injured,  for 
there  are  no  stitch-hole  marks  left  to  tell  the  story.  The  pain  experienced 
after  the  operation  is  trifling  compared  to  the  old  method  of  quilled  or  shotted 
suture.  1  leauv  fitc  stitches  in  for  three  ur  four  weeks,  and  take  great  care 
that  the  rectum  and  vagina  arc  ivashed  out  twice  daily  '  (Lawson  Tait). 

Operation  for  Relaxed  Vaginal  Outlet. 
Kelly  performs  for  the  cure  of  this  condition  a  bi-lateral  symmetri- 
cal operation,  based  upon  the  principle  of  that  of  Emmet.    For  a  more 
complete  description  of  Kelly's  procedure  I  must  refer  the  reader  to 
his  work  on  '  Operative  Gynaecology.' ""'     The  steps  are  as  follows  : — 

The  operation  consists  in  free  denudation  (the  form  and  size  depending  on 
the  degree  of  relaxation)  of  two  triangular  surfaces  on  the  vaginal  sulci  at 
either  side,  the  outline  being  completed  by  a  semi-circular  incision  extending 
around  the  posterior  wall  from  a  point  within  the  hymen  above,  and  embracing 
any  scarred  tissue  below.  A  large  wound  area  is  thus  left,  on  which  is 
seen  a  narrow  undenuded  area  between  the  two  triangles.  The  denudation  is 
effected  with  curved  scissors,  the  whole  thickness  of  the  vaginal  wall  being 
removed  in  strips  from  one-tenth  to  a  fifth  of  an  inch  broad.  Hasmurrbage 
is  checked  in  the  usual  manner,  and,  if  necessary,  buried  sutures  are  used, 
Ajiproximatiou  is  secured  with  silkworm-gut  and  catgut  sutures.  The  mucosa 
of  each  triangle  is  united  at  either  side  with  the  strip  of  undenuded  tissue  in 
the  centre,  and  thus  each  vaginal  sulcus  which  has  been  denuded  is  closed, 
and  the  edges  of  the  remaining  raw  area  below  this  are  brought  together  by 
a  suture  of  silkworm-gut  which  embraces  the  upper  angles  on  the  sides,  and 
transfixes  the  rectocele. 

Howard  Kelly  ridicules  what  he  terms  the  mechanical  theory  of 
the  so-called  perineal  body  being  the  support  of  the  vagina  and 
uterus.  The  real  supporting  mechanism  of  the  outlet,  he  says,  is 
not  the  perineal  body,  but  the  anterior  portion  of  the  levator  ani 
muscle.  Rising  on  either  side  of  the  pubic  ramus,  and  passing  back 
round  the  lateral  vaginal  wall,  it  unites  with  its  fellow  behind  the 
rectum,  its  fibres  being  intimately  interwoven  with  the  lateral  walls 
of  the  rectum.  The  vaginal  introitus  is  but  a  narrow  chink  between 
this  posterior  muscular  band  and  the  pubic  arch.  It  has  no  direct 
means  of  closure  such  as  would  be  afforded  by  a  powerful  sphincter 
muscle.  The  levator  muscle  indirectly  supports  it.  By  its  con- 
traction the  lower  end  of  the  rectum  is  lifted  up  under  the  pubic 
arch,  and  the  vagina  is  flattened  out  and  held  up  between  the  two, 
the  position  of  the  plane  of  the  pubic  arch  rendering  the  closure 

*  '  (!)periitive  Gynaecology,'  by  Howard  A.  Kelly,  2  vols..  1.S9S. 


296 


DISEASES   OF   WOMEN. 


more  efficient.     This  arrangement  it  is  which   gives   the  sigmoid 
curve  to  the  lower  extremity  of  the  virgin  vagina. 

The  fact  that,  notwithstanding  the  absence  of  the  perineum,  pro- 
lapse of  the  vagina  and  uterus  but  rarely  occurs,  Kelly  contends 
is  irreconcilable  with  the  view  that  the  function  of  the  perineum 
is  to  plug  the  pelvic  outlet  '  like  a  cork.'  As  the  tear  extends 
generally  along  the  median  line,  the  lower  fibres  of  the  levator  ani 

muscle     are     uninjured, 


n 


& 


and  hence  prolapse  does 
not  occur.  This  is  not 
the  case  when  the  tear 
branches  laterally. 


Howard  Kelly's  Operation 
for  Complete  Tear  of  the 
Recto  -  Vaginal    Septum.  — 

The  steps  of  the  operation 
are  as  follows  : — 

'  The  area  to  be  denuded 
must  be  outlined  with  the 
scalpel,  which  follows  the 
direction  of  the  scar  tissue 
in  a  general  way,  greatly 
exaggerating  its  outlines ;  the 
cardinal  principle  in  the  de- 
nudation is  to  reproduce  as 
nearly  as  possible  the  origi- 
nal injury. 

'  The  first  incision  splits 
the  septum  and  includes  the 
sphincter  ends,  from  which 
a  line  is  continued  up  under 
the  pubic  arch  on  either 
side  ;  thence  it  goes  down 
into  each  vaginal  sulcus  and 
back  again,  meeting  in  front 
of  the  posterior  column,  1 
to  2  centimetres  (f  to  \  inch) 
above  the  first  incision  in 
the  septum.  All  of  the 
tissue  included  within  the 
outline  is  now  removed.  One 
of  the  sphincter  ends  is  caught  up  with  tissae-foreeps  and  cut  free  with 
curved  scissors.  The  denudation  is  continued  around  the  sharp  edge  of  the 
septum  to  the  opposite  end  of  the  sphincter,  which  is  denuded  in  the  same 
way,  taking  care  to  remove  all  scar  tissue.    A  second  strip  above,  and  parallel 


Fig.  212. — Rkctal  Sutures  not  tied. 
(Howard  Kelly.) 

Silkworm  -  gut  suture  shown  passing  well 
through  the  septum  from  beliind  the  sphinc- 
ter at  either  side. 


i-Ti:nisi:  i>isi'i.aci:mi':n'i\<. 


'I'M 


to  this,  is  next  cut  off;  and  a  third,  and  so  on,  contiiuiiiig  the  denudation  up 
into  the  vagina  until  the  whole  area  within  the  outline  has  been  removed. 
It  is  important  to  bear  iu  mind  that  the  denudation  within  the  vagina  must 
extend  a  centimetre  or  more  {\  inch)  above  the  angle  of  the  tear,  in  order  to 


•>^'\M^s>:-  ■  ■'l^ 


Fig.  213. — Complktk  Te.\r  op  thk  Kectu- 
y.\GixAL  Septum.    (Howard  Kelly.) 

Kectal  sutures  all  tied  except  the  silk- 
worm-gut tension  suture.  The  sutures 
are  shown  introduced  iu  the  right  vaginal 
sulcus. 


Fig.  214. — Eectal  .\nd  V.\gixal 
Sutures  all  tied. 
(HowAHD  Kelly.) 

Perineal  sutures  introduced,  but 
uot  tied. 


avoid  the  tendency  to  form  a  recto-vaginal  fistula  at  this  point.  Silkworm- 
gut  and  catgut  sutures  are  best  adapted  to  the  approximation  of  the  denuded 
surfaces.  Half-deep  sutures  of  catgut  are  preferable  for  closing  the  rectal 
side    of  the    tear,    and   for    securing    accurate  approximation   between   the 


298 


DISEASES   OF   WOMEN. 


sDkworm-gut  sutures,  which  are  used  at  wider  intervals.  The  complication 
of  the  torn  bowel  is  first  disposed  of  by  a  series  of  interrupted  rectal  sutures, 
commencing  at  the  upper  angle  of  the  tear,  entering  each  suture  at  the 
margin  of  the  rectal  mucosa,  and  emerging  on  the  wound  surface  4  to  5  mil- 
limetres (^^0  to  f  inch  distant),  re-entering  on  the  opposite  side  and  coming 
out  again  on  the  margin  of  the  mucosa,  at  a  point  corresponding  to  that  of 
its  entrance.  This  suture  may  be  tied  at  once,  and  dropped  into  the  rectum  ; 
and  a  little  less  than  a  half  centimetre  (i  inch)  below  this,  another  suture  is 
passed  in  like  manner,  tied,  and  dropped,  and  so  on  until  the  whole  of  the 
rectal  rent  has  been  obliterated  down  to  the  sphincter.  One  of  the  most 
important  points  in  the  operation  now  is  to  secure  an  accurate  approximation 
of  the  sphincter  ends  by  two  or  three  sutures  radiating  from  the  rectum  out 
on  to  the  skin  surface.  The  contractions  of  the  sphincter  render  it  necessary 
to  assist  these  sutures  with  one  of  silkworm-gut  introduced  well  behind  to 
the  denuded  ends,  and  passing  up  through  the  septum.  When  this  has  been 
done  the  rectal  rent  is  repaired,  the  wound  is  reduced  from  a  complicated 
one  involving  three  surfaces — rectum,  skin,  and  vagina — to  a  simpler  wound 
involving  vagina  and  skin  perineum. 

Doleris'  Operation. — DoJeris  performs  a  further  modification  of  Tait's  opera- 
tion, which  he  styles  '  Colpoperineoplastie  par  glissement.'  The  minute  steps 
of  this  operation  it  is  not  necessary  to  describe  here.  The  vaginal  flap, 
having  been  raised  and  bared,  is  brought  at  the  middle  point  of  its  base  to 

the  centre  of  the  cutaneous  margin 
of  the  wound.  The  flap  is  then 
fixed  in  its  new  position  by  a 
series  of  sutures,  three  in  number, 
carried  from  the  cutaneous  mar- 
gin through  the  lower  border  of 
the  vaginal  flap  from  one  side  to 
the  other,  beginning  in  the  centre. 
A  final  terminal  purse-string  suture 
of  the  nature  before  referred  to  is 
passed  so  as  to  secure  complete 
and  deep  adaptation  of  the  tissues. 
In  grave  cases,  in  which  there 
is  also  prolapse  of  the  vagina, 
Diihrssen  combines  the  three  steps, 
vaginal  fixation,  anterior  colpor- 
rhaphy,  and  perineorrhaphy,  but 
Edge  advocates  double  lateral  col- 
porrhaphy,  combined  with  vaginal 
fixation  and  perineorrhaphy  — 
firstly,  curettage  and  disinfection 
of  the  uterus ;  secondly,  redisin- 
fection  of  operator  and  assistants, 
and  thorough  cleansing  of  vagina 
and  vulva  ;  thirdly,  vaginal  fixation  as  far  as  the  insertion  of  the  sutures; 
fourthly,  double   lateral  colporrhaphy  as  far    as   insertion  of   the  sutures ; 


Fig.     215.  —  '  Colpopeeineoplastie    pae 

GLISSEMENT,'     SHOWING     THE     TeEMINAL 
PmiSE-STEING    SUTUEE.        (BoKNET    AND 

Petit.) 


UTERINE  DISPLACEMENTS.  299 


fifthly,  tying  of  both  sets  of  sutures.  Continuous  sutures  of  the  finest  silk 
are  used  for  the  colporrhaplij-.  The  vaginal  fixation  sutures  are  removed 
after  six  or  eiglit  Aveeks,  tlie  perineal  after  a  month. 

Operations  for  Vaginal  Prolapse. — The  operations  for  prolapse  of 
the  vaginal  wall  may  be  t-onsidered  in  connection  with  prolapse  of 
the  uterus.  This  vaginal  prolapse  may  be  attended  by  a  rectocele 
or  a  cystocele.  In  the  one  case,  the  rectum  protrudes  into  the 
vaginal  canal,  and  may  be  dragged  down  with  it  outside  the  vulvar 
orifice.  In  the  other,  the  bladder  accompanies  the  prolapse,  fre- 
quently occupying  portions  of  the  procident  mass.  The  position 
and  direction  of  the  urethra  is  altered  (Figs.  195,  196), 

The  pathology  of  this  condition  we  have  considered  in  relation 
to  prolapse  of  the  uterus.*  There  is  little  difficulty  in  detecting 
either  anomaly.  A  soft  bulging  swelling  is  felt,  posteriorly  or 
anteriorly,  pressing  into  the  vaginal  canal,  or  appearing  at  the 
vulva,  and  the  diagnosis  is  further  verified  by  introducing  the  left 
forefinger  into  the  rectum,  while  the  right  is  made  to  oppose  it  from 
the  vaginal  surface.  The  catheter  or  sound  may  be  used  for  a 
similar  object  in  the  instance  of  a  cystocele. 

Operations  intended  to  produce  Contraction  of  the  Vaginal  Canal 
— Colporrhaphy. — The  principle  of  this  operative  pi'ocedure  consists 
in  the  removal  from  the  vagina  of  portions  of  the  mucous  membrane 
from  the  anterior,  lateral,  or  posterior  wall,  or  from  all  three.  The 
shape  and  extent  of  the  portions  removed  will  depend  upon  the 
nature  of  the  individual  case  and  the  degree  of  prolapse. 

The  simplest  of  operative  measures  is  that  of  Marion  Sims.  It  consists 
of  the  following  steps  :  First,  the  anterior  wall  of  the  vagina  (which  is  the 
primarily  prolapsing  portion)  is  hooked  up  and  down  well  towards  the  posterior 
wall ;  secondly,  with  Emmet's  or  Sims'  scissors,  a  V-  or  trowel-shaped  portion 
of  the  mucous  membrane  is  removed,  the  apex  at  the  neck  of  the  bladder, 
and  the  arms  extending  to  the  sides  of  the  cervix  uteri ;  thirdly,  the  denuded 
surfaces  are  brought  together  by  sutures  (of  silver  wire  or  silkworm-gut) 
passed  transversely.  Sims,  in  his  later  operations,  left  a  small  portion  of 
undenuded  tissue  at  (e)  to  permit  the  escape  of  any  pent-up  secretion  (Fig.  216). 

It  has  to  be  remembered  that  we  have  four  distinct  abnormal 
states  to  consider  in  connection  with  this  operation  :  relaxation  of 
the  uterine  supports  or  ligaments,  primary  prolapse  of  the  vagina 
(antecedent  to  the  prolapsus  uteri),  hypertrophic  elongation  of  the 
cervix,  and  prolapsus  uteri.  Associated  with  the  descent  of  the 
uterus  are  the  two  fundamental  errors — want  of  vaginal  support, 
and  uterine  traction.  Increase  of  uterine  weight  is  the  third  most 
*  Pages  278-290 ;  also  see  chapter  Anatomical  and  Clinical. 


300  DISEASES   OF   WOMEN. 


important  factor.     Any  operation   which    can    carry    with   it   the 

assurance  of  correcting  all  these  conditions  is  the  only  one  that  can 

give  a  guarantee  of  any  permanent  result. 

The  denudation  of  the  vaginal  mucous  membrane  may  be  effected 

with    either    scissors    or    the    colporrhaphy 

knife  (Fig.  217).    I  employ  both  instruments 

at  different  stages  of  the  operation.     Good 

gut  ligatures  are  the  best  to  use.     Simon 

performed    anterior    colporrhaphy    by    the 

removal  of  an  oval   portion  of  the  vaginal 

mucous    membrane,    the   poles  of    the  oval 

being  pointed  and  brought  to  an  acute  angle. 

The  lona:  diameter  of  the  denuded  surface 

corresponds  to  the  relaxed  portion   of   the 

_    /  vaginal  wall.     The  shape  of  the  flaps,  how- 

^  ever,  must  depend  in  a  great  measure  upon 

the  size  and  situation  of  the  prolapse.     The 

Fig.  216.— Sims'  Colpor-     ,  i     .         ^   ,,  ■,  i     -i         c 

„„.„„,,  boundaries  oi  the  apex,   base,  and  sides  or 

RHAPHY.  ■*■ 

the  proposed  raw  surface  are  limited  by 
fixing  forceps.  The  number  and  direction  of  the  sutures  will 
depend  upon  the  size  and  shape  of  the  colporrhaphy.     In  all  these 


Fig.  217. — Colpokehapht  Knife  ok  Martin. 

operations  it  is  essential  to  operate  with  celerity,  and  to  restrain 
the  haemorrhage  by  irrigation  with  hot  water. 

Gerstung,*  on  the  theory  that  vaginal  cystocele  is  the  result  of  either 
laceration  or  extreme  stretching  of  the  vesico-vaginal  fascia,  on  which  the 
bladder  rests,  recommends  that  the  anterior  vaginal  wall  be  split  in  its  whole 
length,  and  that  the  part  of  the  bladder- wall  which  prolapses  be  pushed 
towards  the  interior  of  the  bladder  ;  then  by  means  of  numerous  sutures  the 
paravesical  cellular  tissue  or  fascia  to  be  drawn  together  in  a  long  fold  or 
plait,  so  as  to  form  a  sure  support  for  the  vesical  wall.  The  vaginal  incision 
is  then  closed, 

Colpoperineorrhaphy. — Various  procedures  are  practised  with  a 
view  of  curing  a  rectocele  and  a  prolapse  of  the  vagina.  When 
such  a  prolapse  occurs  with  a  lacerated  or  deficient  perineum,  col- 
poperineori'haphy  is  performed. 

*  Centralh.f.  Gyn.,  Feb.,  1897. 


UTERINE    D/SI'LACEMENTS. 


301 


The  principle  of  Eeamy's  operation  is  shown  in  Fig,  220,  The  desired 
extent  of  surface  of  the  posterior  wall  of  the  vagina  is  denuded,  as  shown  in 
the  drawing,  two  arms  of  the  wound  being  carried  upwai'ds  and  outwards  at 


Fig.  218. — Anterior  Colporrhaphy, 
showing  the  sutdbes  that 
CLOSE     THE      Thin      Angles. 

(DOLERIS.) 


Fig.  219. — Anterior  Colporrhaphy, 
showing  the  passage  of  the  final 
Suture,  u,  r,  x,  y.     (Doleris.) 


each  side  of  the  cervix.  Catgut  ligatures  are  used.  A  most  important 
suture  is  that  shown  bj'  the  dotted  lines  crossing  the  upper  wings  of  the 
wound ;  this  suture  is  earned  from  the  angle  formed  by  one  extending  arm 


Fig.  220. — Keajiy's  Operation  for  RECTOctLE. 

with  the  denuded  surface  on  the  posterior  wall,  to  the  angle  of  undenuded 
surface  beneath  the  cervix.  It  is  drawn  out  here  and  reintroduced  at  a  cor- 
responding point  of  the  apex,  about  one-fourth  of  an  inch  from  its  point  of 


302 


DISEASES   OF    WOMEX. 


emergence, .  and  is  carried  across  the  denuded  arm.    It  is  brought  out  a 
quarter  of  an  inch  from  the  margin  at  a  coiTesponding  spot  (in  the  opposite 

angle)  to  the  point  of  entrance. 
This  suture  brings  the  three 
angles  of  the  wound  together 
(Fig.  220). 

The  form  of  Hegar's  operation 
is  triangular,  with  the  apex  at 
the  neck  of  the  uterus,  and  the 
base  at  the  perineum.  That  of 
Martin  is  shown  in  Fig.  221. 
The  denuded  surface  is  divided 
into  two  portions  by  a  column 
of  mucous  membrane,  which  he 
purposely  leaves.  Martin  closes 
the  vaginal  wound  before  he 
vivifies  the  perineal  edges.  There 
is  danger  of  non-union  occurring 
through  the  untouched  central 
column  of  mucous  membrane. 

Sims'  Amputation  of  the 
Cervix. — This  operation  is 
more  frequently  performed 
on  those  advanced  in  life. 
The  best  method  of  removal 
is  by  means  of  the  knife  or 
scissors.  The  stump  is  covered  with  the  vaginal  tissue  by  means  of 
silver  sutures,  four  to  six,  passed  from  before  backwards  through  the 
cut  edges  of  the  vagina.  Thus  a  small  oval 
opening  corresponding  to  the  cervical  canal 
is  left.  Emmet  drew  particular  attention  to 
the  evils  which  accrue  to  the  woman  if  the 
stump  be  allowed  to  heal  by  granulation. 
These  are  partially  due  to  contraction  or 
closure  of  the  uterine  canal  and  siibsequent 
re-enlargement  of  the  uterus,  and  partly  to 
reflex  irritations  and  the  effects  on  nutrition. 
Schroeder's  Operation.— For  this  we  re- 
quire a  duckbill  speculum:  two  vaginal 
retractors;  two  long-toothed  forceps:  two 
scalpels,  with  short  broad  blades;  a  pair 
of  straight  and  strong  scissors ;  a  dozen 
small  haemostatic   forceps,  including  two  of   Kocher's  and  two  of 


Fig.  221. — Colpopeeixeoeehapht. 
(Maetin's  Method.) 


Fig.  L222. — Amputatiox 
the  Ceevix.     (Sims.) 


UTER  INK   I)  ISP  LA  CEMENTS. 


303 


Zweifel's  small  angiotribes ;  a  few  toothed  forceps ;  an  irri- 
gator ;  special  needles,  flat  and  curved,  with  needle-holder ;  catgut 
and  silver  wire  ;  and  a  receptacle  for  the  irrigating  fluid.  The 
neck,  which  is  drawn  down  and  held  tirmly  by  an  assistant,  is 
bilaterally  divided  as  far  as  the  vaginal  fold.  The  divided  lips  are 
then  well  separated,  and  a  curved  incision,  with  the  convexity 
anteriorly,  is  made  at  each  angle.  Another  semicircular  incision  is 
now  carried  to  the  depth  of  some  millimetres  through  the  uterine 
tissue,  from  one  angle  of  the  denuded  anterior  lip  to  the  other  ; 
and  the  bistoury  being  then  turned  flat  in  the  groove,  it  is  carried 
through  the  uterine  neck  at  right  angles  to  the  transverse  incision. 


Fig.  223. — Schroder's  Opekation  of  Am-  Fig.  224. — Sectioxal  View  of  same. 

PUTATiox  OF  Yagixal  Ceryix,  SHOWING  ^^  g^  ^^  e^^o^^d.  surfaces  of  flap- 

the  Track  of  the  Central   Suture  j)^  ^  p^  ^^.^^j,  ^f  supra-vaginal 

ACROSS  THE  ExsECTED  LiPS.     (BoxxET  incision  ;  A,  F,  suture. 
and  Petit.) 

leaving  thus  a  raw  surface,  as  shown  in  the  figure.  This  angle  is 
then  united  by  three  sutures.  The  curved  needle  of  Sims  is  carried 
in  the  manner  shown  in  the  drawing  beneath  the  exposed  surfaces, 
entering  at  a  short  distance  from  the  margin  of  the  first  incision, 
and  emerging  at  the  upper  third  of  the  larger  flap,  to  be  re-entered 
again  at  the  lower  third.  The  central  suture,  before  tying,  is  shown 
in  Fig.  223.  This  one  is  first  inserted :  the  three  are  caught  in  a 
torsion  forceps,  and  left,  while  the  anterior  lip  is  being  treated  in 
the  same  manner.  When  the  two  denuded  lips  have  been  sutured 
they  are  drawn  asunder  by  the  threads,  and  the  borders  of  the 
lateral  incision  are  freshened.  These  are  next  carefully  united  at 
either  side  by  suture.     Atresia  is  prevented  by  securing  the  exact 


304  DISEASES   OF    WOMEN. 


adjustment  of  the  cervical  and  vaginal  mucous  surfaces  of  both  lips 
and  by  preventing  any  intervening  protrusions  between  the  sutured 
points.  Also  the  external  os  uteri  is  made  slightly  larger  than 
natural,  and  is  kept  open  at  the  close  of  the  operation  by  the 
insertion  of  some  iodoform  gauze. 

Martin's  Operation. — The  cervix  having  been  seized  with  two 
tenacula,  or  by  a  few  strong  threads  of  silk  which  are  passed 
through  and  tied,  is  drawn  well  down.  An  anterior  incision  is 
carried  across  the  uterine  wall,  and  the  mucous  membrane  raised  as 
far  as  the  vaginal  vault,  avoiding  the  bladder  and  the  peritoneum. 
Two  lateral  incisions  are  now  made,  dividing  the  uterine  neck  as 
far  as  either  extremity  of  the  transverse  cut.  The  anterior  flap 
is  formed  by  a  triangular  incision  through  the  anterior  uterine 
wall,  which  is  thus  excised.  The  mucous  membrane  is  now 
stitched  with  a  series  of  catgut  sutures  to  the  uterine  mucosa.  The 
posterior  flap  is  made  in  a  similar  fashion,  and  it  also  is  united 
to  the  mucosa.  Other  sutures  are  passed  laterally,  bringing  the 
mucous  membrane  together,  and  leaving  the  opening  of  the  uterine 
canal  at  the  most  dependent  part.  The  operation  may  then  be  ampli- 
fied by  lateral  anterior  and  posterior  colporrhaphy,  or,  after  thorough 
disinfection  of  the  hands,  ventro-fixation  may  be  performed. 

Simon  Markwald  operates  by  the  removal  of  a  cone-shaped  portion 
of  each  lip,  with  the  base  below.  These  two  flaps  are  united  by 
catgut  sutures,  and  the  lateral  incisions  are  brought  together  as  in 
Schrceder's  operation. 

Other  operative  procedures  practised  in  extreme  cases  of  vaginal  proci- 
dentia, are  episiorrhaphy  (Le  Fort),  fixation  of  the  vagina  (Pean),  colpo- 
hysteropexy  (Sanger,  Nicoletis,  Eichelot),  colpectomy  (Miiller). 

Episiorrhaphy  is  closure  of  the  vaginal  opening.  It  may  be  occluded  to  the 
extent  of  complete  closure,  a  space  being  left  for  the  passage  of  the  urine  ; 
or  it  may  only  be  so  contracted  as  to  permit  coitus.  Le  Fort  bares  two 
rectangular  surfaces— one  on  the  anterior,  and  the  other  on  the  posterior, 
waU  of  the  vagina,  and  unites  these  by  sutures.  Pean  fixed  the  vagina  to  the 
rectum  behind,  and  to  the  bladder  in  front.  In  colpohysteropexy  the  neck 
of  the  retroverted  uterus  is  amputated,  and  the  posterior  vaginal  wall  is  fixed 
to  the  anterior  edge  of  the  uterine  stump.  Three  catgut  sutures  are  used  to 
attach  the  posterior  half  of  the  uterine  stump  to  the  posterior  lip  of  the 
vaginal  incision.  Other  sutures  pass,  at  each  side,  from  this  same  lip  to  the 
anterior  edge  of  the  uterine  stump,  and  these  include  the  vaginal  mucous 
membrane,  so  as  to  cover  the  lateral  portion  of  the  uterine  surface  mth  it. 
The  remaining  margins  of  the  vaginal  wound  are  then  brought .  together  by 
sutures.  The  operations  of  Byford,  v.  Eabenan,  and  Jacobs,  are  but  modifi- 
cations of  these  methods  (anterior  and  double  colpohysteropexy). 


VTEinNi:    nrSPLACEMENTS.  305 


Shortening"  of  the  Utero-Sacral  Ligaments. 

The  structure  of  the  uteio-sacral  ligaments  has  ah-eady  been 
referred  to.  Schultze  described  these  in  1881,  and  specially  drew 
attention  to  their  muscular  structure.  Passing  from  a  little  below 
the  junction  of  the  cervix  to  the  body,  these  muscular  bands  in 
the  folds  of  Douglas  reach  to  the  lateral  part  of  the  sacrum  at  a 
level  of  the  second  vertebrae,  losing  themselves  in  the  muscular 
wall  of  the  rectum,  and  in  the  sub-serous  connective  tissue.  Some 
muscular  fibres  coalesce  and  form  Luschka's  musculus  retractor  uteri, 
this  being  their  lower  insertion.  Relaxation  of,  or  injury  to,  these 
utero-sacral  ligaments  tends  to  produce  both  retro-displacement 
and  prolapse.  As  far  back  as  1850,  Amussat  brought  about  con- 
traction of  the  posterior  fornix  by  the  application  of  caustic  potash 
and  the  actual  cautery.  By  various  methods,  both  by  the  abdomen 
and  vagina,  Herrick,  Byford,  Frommel,  Freund,  Sanger,  Wer- 
theim,  and  Mandl  have  successfully  operated,  but  attention  had 
been  more  prominently  di-awn  to  this  method  by  Bovee,  who 
shortened  the  utero-sacral  ligaments  through  the  vagina  in  1897, 
and  later,  in  1900,  attacked  them  by  the  abdominal  route.  Jessett 
brought  the  subject  before  the  British  Gynaecological  Society.  He 
advocated  posterior  fixation  of  the  cervix  with  ventro-fixation, 
and  Stanmore  Bishop  reviewed  the  entire  subject,*  describing  the 
technique  of  the  operation  as  performed  by  him.  In  Bovee's  vaginal 
operation,  the  posterior  lip  of  the  cervix  is  grasped  with  a  volsellum 
and  drawn  forward,  an  antero-posterior  incision  is  carried  through 
all  the  structures  of  the  posterior  fornix,  avoiding  the  peritoneum, 
and  extending  from  the  cervix  to  the  rectum.  The  ligaments  are 
then  exposed  by  dissection,  and  both  are  treated  thus  :  They  are 
grasped  with  a  forceps  midway  between  the  extreme  points  to  be 
united,  and  a  fold  of  a  ligament  is  brought  into  the  vagina,  the 
traction  on  the  cervix  being  relaxed.  A  curved  needle,  armed  with 
kangai'oo  tendon,  is  passed  through  the  ligament  at  the  extreme 
points,  and  another  through  the  loop  thus  formed,  including  the 
posterior  portion  of  the  cervix  below  the  insertion  of  the  ligaments. 
The  deep  sutures  are  first  tied,  and  then  the  others.  The  wound  is 
now  spread  well  open,  and  the  two  ends  are  brought  together  by  a 
continuous  suture.  Occasionally,  Bovee  separates  the  anterior 
vaginal  wall  from  the  uterus,  and  transplants  the  former  higher  up 

*  Brit.  Gyn.  Jour.,  Feb.,  1903. 

X 


306  DISEASES  OF   WOMEN. 

to  it.  Should  adhesions  exist  in  the  posterior  cul-de-sac,  he  opens 
this  and  separates  them.  Through  the  anterior  fornix  he  also 
shortens  the  round  ligaments. 

Should  he  follow  the  abdominal  route,  he  adopts  the  Trendelen- 
burg position,  and  removing  the  intestine  with  the  omentum  out  of 
the  way,  by  a  specially  long  retractor  he  draws  the  uterus  well 
forwards  and  upwards.  Having  with  the  fingers  carefully  located 
the  utero-sacral  ligaments,  a  longitudinal  incision  is  made  near 
the  inner  margin  of  one  of  them,  through  the  peritoneum,  which 
is  then  partially  dissected  loose,  and  a  fold  of  it,  together  with  the 
loop  formed  as  in  the  vaginal  operation,  is  treated  as  in  the  latter 
technique.  The  peritoneum  is  closed  by  a  purse-string  suture,  or 
by  the  method  adopted  in  closing  the  vaginal  wound.  The  same 
technique  is  followed  with  the  other  ligament,  and  the  abdomen  is 
then  closed. 

Where  the  vaginal  route  is  chosen,  if  the  round  ligaments  are 
not  shortened,  the  abdomen  is  not  opened. 

Stanmore  Bishop  selects  the  aponeurotic  structures  covering  the 
anterior  surface  of  the  sacrum  for  the  attachment  of  the  cervix, 
carefully  avoiding  the  ureter  and  rectum,  and  the  nerve  sti'ands. 
He  selects  a  point  between  the  rectum  on  the  inner,  and  the  ureter 
on  the  outer,  side,  which  is  fairly  free  from  vessels.  His  technique 
is  as  follows  : — 

The  extreme  Trendelenburg  position  is  adopted.  The  uterus  and 
broad  ligaments  being  isolated  from  the  intestines,  two  threads,  one 
on  either  side  of  the  uterus,  are  passed  through  the  broad  ligament, 
and  enclosing  the  tube  and  round  ligament.  These  are  used  as 
tractors  to  draw  the  uterus  forwards.  An  obturator  or  flattened 
uterine  sound  is  passed  into  the  vagina  by  an  assistant,  and  carried 
against  the  posterior  fornix  so  as  to  render  it  prominent.  '  On 
either  side  a  stout  silk  thread  is  passed  vertically  through  the  sub- 
stance of  the  fornix,  avoiding  the  mucous  lining,  so  that  each 
protruding  end  is  half  an  inch  distant  from  the  other,  and  the 
whole  loop  one-third  of  an  inch  from  the  cervix.  The  fornix  is  now 
applied  in  the  position  just  described,  and  the  needle  carrying  the 
suture  is  entered  deeply,  embracing  the  periosteum  covering  the 
sacrum,  being  bi'ought  out  again  half  an  inch  directly  above  its 
point  of  entrance.  A  narrow  strip  of  peritoneum  is  next  removed 
from  the  portion  of  the  fornix  lying  in  the  grip  of  the  suture,  so  as 
to  bare  the  connective  tissue.  The  same  plan  is  pursued  at  the 
opposite  side,  and  the  sutures  are  then  tied.     The  traction  threads, 


UTElilSE   DISPLACEMENTS.  307 

which  have  been  passed  through  the  broad  ligaments,  are  now 
removed.  The  round  ligaments  are  shortened,  and  the  abdominal 
toilet  is  completed.'  At  a  later  sitting,  if  necessary  ..perineorrhaphy 
is  performed. 

Muller's  Colpectomy. — In  cases  of  complete  vaginal  prolapse,  and 
in  which  the  vagina  is  no  longer  required  for  physiological  or  sexual 
purposes,  Peter  Miiller  excises  the  whole  vagina,  and  leaves  the 
uterus  intact.  The  operation  is  thus  described  by  Rene  Koenig 
(Berne)  :  * — 

'  The  cervix  Ijeing  drawn  down,  and  the  vagina  unfolded,  the 
mucous  membrane  is  cut  through  about  half  an  inch  from  the 
shallow  recess  left  between  the  vagina  aud  the  labia  minora.  Then, 
beginning  from  this  section,  which  is  conducted  round  the  vagina, 
the  entire  mucous  membrane  is  stripped  off — as  a  rule,  an  easy  and 
rapid  operation,  a  few  strokes  of  the  knife  only  being  necessary,  in 
addition  to  a  steady  traction,  to  scalp  off  the  whole  vagina.  Should 
the  cervix  be  hypertrophied,  a  clean  cut  with  scissors  or  bistoury 
will  remove  it.  Now  the  bed  of  the  removed  vagina  is  columnized  loith- 
out  regard  to  the  uterus.  Beginning  at  the  middle  of  the  raw  surf  ace, 
the  portions  of  the  vagina  immediately  surrounding  the  cervix  are 
approximated  by  means  of  a  few  stitches,  over  which  two  or  three 
layers  of  sutures  are  put  from  side  to  side.  It  is  not  necessary  to 
interrupt  the  suture  after  each  layer  has  been  completed,  one  con- 
tinuous suture  being  sufficient  for  the  whole  operation,  including 
the  closing  of  the  most  superficial  layer,  the  mucous  membrane 
itself.  As  the  suturing  proceeds,  the  uterus  recedes  of  itself. 
Should  there  be  much  bleeding,  a  few  ligatures  may  be  applied, 
but,  as  a  rule,  the  haemorrhage  is  readily  checked  by  the  continuous 
suture,  if  care  be  taken  to  include  the  bleeding  vessel  in  the 
stitch." 

Koenig  has  performed  colpectomy  in  women  of  advanced  life 
without  general  anaesthesia.  The  operation  is  not  a  tedious  one, 
being  performed  within  fifteen  minutes,  and  recovery  is  rapid.  As 
to  the  consequences  to  the  uterus,  so  far  there  has  been  no  report 
of  any  accumulation  of  fluid  or  other  effects,  an  atrophic  condition 
usually  resulting.  He  claims  for  the  operation,  simplicity,  dispensa- 
tion of  anaesthetics,  rapid  recoveiy,  impossibility  of  recurrence,  and 
a  maximiim  of  safety. 

*  Jour.  Obstet.  and  Gyn.  of  Brit.  Emp..  Sept.,  190:?. 


308  DISEASES   OF    WOMEN. 

Hysterectomy  with  Colporrhaphy  for  Total  Prolapse. 

This  operation  originated  principally  in  the  Dresden  Klinik,  at 
the  hands  of  Leopold  and  Wolff. 

In  regard  to  this  radical  procedure,  which  has  not  hitherto  found 
many  advocates  in  this  country,  we  would  quote  the  dictum  of 
Wolff  himself,  viz. :  '  Tlie  danger  of  a  surgical  proceeding  should  be  at 
least  not  greater  than  the  danger  to  life  of  the  cc7tdition  which  the  opera- 
tion is  destined  to  cure.'  When  we  find  that  a  mortality  of  16*6  per 
cent,  followed  the  performance  of  the  operation  in  the  most  capable 
hands,  we  may  pause  before  advising  so  radical  a  measure  for  a 
condition  which  in  itself  is  not  dangerous  to  life,  notwithstand- 
ing its  consequences  and  inconveniences.  To  perform  a  grave 
and  protracted  operation  on  an  aged  patient  with  emphysema 
of  the  lungs,  with  cardiac  hypertrophy  and  dilatation,  is  only  to 
bring  the  gynaecologist's  art  into  disrepute.  At  least,  when  we 
have  failed  with  all  forms  of  support  to  give  relief,  the  less  danger- 
ous steps  of  colporrhaphy  and  abdominal  fixation  should  first  be 
tried,  before  we  advise  the  removal  of  the  uterus. 

On  the  other  hand,  there  must  occur,  and  not  infrequently,  cases 
in  which  no  support  can  be  applied,  nor  can  we  hope  for  cure  from 
any  vaginal  operation  ;  and  this  means  a  life  of  misery  to  the 
patient  whose  daily  bread  may  depend  upon  her  ability  to  work. 
Morbid  processes  also  may  have  occurred  in  the  procident  tumoui", 
and  the  bladder  be  involved.  Here,  amputation  of  the  cervix  or 
hysterectomy  is  justifiable,  and  should  be  performed,  the  patient 
having  been  told  the  risks  of  the  operation. 

Case  of  Extreme  Procidentia  Uteri  with  Fibroma  and  Prolapse  of 
the  Bladder  of  Fifteen  Years'  Duration — Hysterectomy  with 
Ablation  of  Portion  of  Vagina.     (Plate  XIV.) 

Patient  had  been  married  sixteen  years,  and  had  six  children.  Uterus  was 
first  prolapsed  fifteen  years  since,  after  the  birth  of  her  first  child.  It  then 
yielded  to  treatment  till  the  birth  of  the  fourth  child.  She  had  been  gradually 
becoming  worse  since,  especially  for  the  last  few  years,  and  had  worn  a 
support  and  belt,  which  did  not  give  relief.  Her  occupation  demanded  con- 
tinual standing.  A  large  procidentia  protruded  between  the  thighs,  and  the 
uterus  could  be  felt  considerably  enlarged.  There  was  a  deep  erosion  round 
the  OS  uteri,  with  a  suppurative  discharge  from  the  endometrium.  The  sound 
passed  for  about  four  inches  downwards  into  the  procident  mass  almost  to  a 
level  with  the  external  os.  The  catamenia  were  very  frequent,  dark  in 
■"olour,  and  there  was  profuse  bleeding. 


PLATE 
XIV. 


o 


PLATE    XV. 

Case  II. 

Senile        Atrophic 
Utekus     kemoved 

FROM        PkOCIDEXT 

Sac  after  the 
Keturx  of  the 
Bladder    and 

IvECrCil    INTO    THi: 

Pelvic  Cavity,  in 
a  Patient  aged  74. 

(AUTHOK.) 

Prolapse   of  twenty- 
five  years'  duration. 


[To  face 
p.  308. 


PLATE   XVI. 


Case  I.  (p.  308). — Sectional  Drawing,  showing  Extent  op  Adhesions 
TO  THE  Bladder. 


PLATE   XVII. 


Case  II.  (p.  309). — Sectional  Drawing,  showing  Extent  of  Adhesions 
OF  THE  Sac  Wall,  Bladder,  and  Eectum. 

^    ■  ITo  face  p.  309. 


UTEIUNE  DISPLACEMENTS.  309 


The  uterus  was  removed  and  a  portion  of  the  prolapsed  vagina  ablated. 

The  difficulty  of  the  operation  consisted  in  the  freeing  of  the  bladder  from 
the  uterus,  to  which  it  was  adherent,  as  may  be  seen  from  the  plate,  for  the 
greater  part  of  its  anterior  surface.  This  was  done  by  alternative  working 
towards  the  uterus  with  the  finger-nail,  curved  blunt-pointed  scissors,  and  a 
small  piece  of  sponge  or  gauze  on  a  holder.  There  was  an  interstitial  fibroid 
in  the  fundus  of  the  uterus.  The  rectum  was  partly  adherent  behind.  A 
flap  of  vagina  was  removed  at  either  side.  The  peritoneum  was  laterally 
united  with  the  vagina,  a  sterilized  iodoform  drain  was  passed  into  the  peri- 
toneal cavity,  and  the  patient  was  treated  as  after  an  ordinary  vaginal  hyste- 
rectomy. The  patient  made  an  admirable  recovery,  being  out  of  bed  on  the 
twenty-first  day  after  the  operation,  and  returning  home  on  the  twenty-sixth. 
She  has  been  perfectly  comfortable  ever  since,  and  there  has  been  no  tendency 
to  the  least  return  of  the  prolapse  of  the  vagina. 

Case  of  Extreme  Procidentia  Uteri  of  Twenty-five  Years'  Duration 
with  Prolapse  of  Bladder  and  Bowel,  and  Adhesions  both  to 
the  Sac  Wall  and  the  Uterus — Hysterectomy — Ablation  of 
Portion  of  Vagina.    (Plate  XV.) 

Mrs.  S.,  aged  74,  suffered  from  prolapse  for  twenty-five  years.  Of  late  she 
had  been  entirely  confined  to  the  house  and  unable  to  walk.  In  addition 
there  was  inability  to  control  the  bowel,  and  she  had  difBcidty  also  in  empty- 
ing the  bladder.  The  tumour  bore  all  the  evidences  usually  present  in  old 
prolapse.  The  uterus  coidd  be  felt  atrophied  and  fiddle-shaped  in  the  centre 
of  the  mass.  The  bladder  reached  close  to  the  lower  margin  of  the  cervix. 
The  cervical  canal  was  closed  a  short  distance  from  the  os  uteri ;  the  latter 
was  eroded,  there  was  purulent  discharge  and  ulceration  in  the  surrounding 
edges  of  the  cervix.  The  operation  performed  was  the  same  as  in  the  last 
case,  only  much  more  difficult.  The  bladder  wall  was  practically  one  with 
the  wall  of  the  sac  in  front,  and  had  to  be  slowly  dissected  off  in  the  manner 
mentioned  before.  The  ureters  were  exposed  in  doing  this.  The  posterior 
surface  of  the  bladder  was  adherent  to  the  uterus,  and  this  also  had  to  be 
detached.  The  bladder  was  now  free.  The  uterus  was  brought  down,  and 
the  broad  ligaments  were  ligatured  at  each  side  by  three  ligatures  which  in- 
cluded all  vessels.  In  doing  this  the  rectum  was  found  partly  adherent  to 
the  upper  and  posterior  part  of  the  uterus,  and  this  was  freed.  The  uterus 
was  now  removed,  the  bladder  being  returned  into  the  pelvis  and  supported 
there  by  iodoform  gauze.  The  rectum  was  pushed  up  from  below,  and  dis- 
sected ofl'  from  its  attachment  to  the  posterior  wall  of  the  sac ;  it  was  also 
returned  into  the  pelvis,  and  supported.  A  semi-circular  flap  was  now  cut 
anteriorly  and  posteriorly  from  the  vagina.  The  peritoneal  edges  were 
brought  together  with  those  of  the  vagina  and  the  vault  closed,  and  the 
vagina  tamponed  Avith  iodoform  gauze.  The  patient  was  out  of  bed  in  three 
weeks. 

It  is  now  several  years  since  these  patients  were  operated  upon,  and  they 
are  still  in  complete  comfort. 

A  patient,  aged  -42,  with  prolapse  of  fourteen  years'  duration,  was  operated 


310 


DISEASES   OF    WOMEN. 


Fig.  225. — Dissection  of  the  Uterus  in  Two  Parts,  from  behind  forward. 

(Doyen.) 
The  fundus  having  been  drawn  down  througli  the  pouch  of  Douglas. 


Fig.  226. — Complete  Severance  of  the  Uterus — The  Neck  above — 
-   Protrusion  of  the  Bladder.    (Doyen.) 


I 


UTERINE  J)ISPLACEMENTS.  311 

upon  by  the  aiitlior,  antl  cnred  by  fixatii)n  of  \\\v  uterus.     Here,  liowevcr,  the 
uterus  was  healthy. 

Doyen's  Operation  of  Panhysterectomy  for  Inveterate  Prolapse. — Doyen 
remarks  on  tlie  dillicuhies  wliieli  liave  to  be  contended  with  in  tVeemg  the 
bladder  in  these  eases  and  in  ablating  the  uterus.  The  operation  he  performs 
he  divides  into  five  stages,  or  six  if  colpoperineorrhaphy  be  performed,  lie 
first  opens  the  pouch  of  Douglas,  and,  drawing  the  neck  of  the  uterus  well  up 
and  in  front,  enlarges  the  opening  and  brings  the  fundus  of  the  uterus  down. 
He  next  divides  the  uterus  by  a  posterior  section  as  far  as  the  fundus, 
continuing  along  the  anterior  wall  until  he  arrives  at  the  bladder,  which 
he  cautiously  detaches.  The  uterus  is  thus  brought  in  two  halves  into  a 
state  of  retroversion.  The  mucous  membrane  of  the  anterior  vaginal  cul-de- 
sac  is  now  divided,  and  any  attachments  of  the  neck  are  separated  with  the 
fingers.  Should  there  be  bleeding,  it  is  arrested  by  forceps.  The  adnexa 
are  now  ligatured  and  the  pedicle  secured,  the  broad  ligaments  being  first 
tied  en  masse,  and  then  secured  in  two  halves  by  transfixion.  The  bladder 
being  replaced,  either  half  of  the  uterus  is  convenient  for  traction  on  the 
broad  ligaments,  and  for  facilitating  the  peritoneal  toilet  and  the  section  of 
the  broad  ligaments.  We  are  then  enabled  to  close  the  peritoneum  com- 
pletely after  resection  of  the  uterus,  by  bringing  its  anterior  and  posterior 
flaps  together,  while  we  fix  the  pedicles.  Pie  finishes  the  operation  by  the 
performance  of  an  anterior  colporrhaphy  and  a  perineorrhaphy. 

Ascent  of  Uterus. — The  uterus  recedes  from  the  reach  of  the 
examining  finger.  It  is  well  to  bear  in  mind  in  practice  that  this 
recession  of  the  uterus  may  be  associated  with  (a)  pregnancy  ;  here 
we  have  (after  the  third  month)  the  other  local  signs  of  pregnancy  ; 
(h)  ovarian  tumours — frequently  in  ovarian  disease  the  uterus  is  not 
only  drawn  up  from  the  pelvis,  bvit  the  cervix  is  shortened,  and  the 
OS  uteri  may  be  felt  almost  on  a  plane  with  the  vaginal  roof  ;  (c) 
fibrous  and  fihro-cystic  disease  of  the  uterus;  (d)  abdominal  tumours 
(springing  from  or  connected  with  the  abdominal  viscera),  as 
hydatid  tumours,  cystic  growths,  malignant  disease ;  {c)  peritoneal 
effusion  (hsemorrhagic,  serous,  or  purulent),  pelvic  and  abdominal, 
with  consequent  adhesions  ;  (/)  pelvic  tumours,  occurring  in  con- 
nection with  the  rectum  or  vagina,  or  in  Douglas'  space.  It  is  a 
matter  of  considerable  importance  in  arriving  at  a  diagnosis,  when 
we  discover  a  receding  uterus,  to  determine  carefully  which  of  these 
conditions  are  operating  in  causing  a  recession  of  the  organ. 

Diiferentiation  of  Causes  of  Ascent. 

The  following  table  may  assist  in  the  differentiation    of  the    conditions 
which  may  cause  upward  displacement  of  the  uterus. 

Early  Pregnancy. — Uterine  neck— shortened   and   softened.      Os  uteri  soft, 
directed  backwards — uterine  fundus  globular. 


312  DISEASES  OF   WOMEN. 

Ovarian  Tumour. — Cervix  uteri  considerably  shortened,  but  not  softened  as  in 
the  pregnant  condition ;  os  uteri  unaltered ;  often  hard  and  possibly  of 
the  sterile  type  ;  uterine  canal  normal  in  length. 

Fibromyomata  and  Fibro-cystic  Tumours. — Cervix  frequently  hard,  giving  the 
characteristic  feel  of  fibrous  development ;  often  conical  in  shape ;  the 
mucous  envelope  movable  over  the  interstitial  tissue ;  uterine  canal 
lengthened ;  continuity  of  tumour  with  uterus  diagnosed  bimanually 
and  hy  the  uterine  sound. 

Abdominal  Tumours. — The  entire  uterus  is  frequently  displaced,  and  pushed 
out  of  position  to  either  side,  or  backwards  towards  the  pouch  of  Douglas. 
The  cervix  is  unaltered  in  size  or  consistence.  The  os  uteri  may  or  may 
not  be  of  the  normal  character,  so  far  as  shape  and  size  are  concerned. 
The  uterus  in  the  majority  of  cases  can  be  moved  with  the  sound  inde- 
pendently of  the  tumom\  By  bimanual  examination  it  will  be  disasso- 
ciated from  the  latter,  while  the  uterine  canal  will  be  found  of  the  normal 
length. 

Peritoneal  Effusions. — The  uterus  is  frequently  fixed,  or  moved  with  difficulty. 
The  cervix  in  pelvic  effusions  is  often  soft  and  swollen,  and  sensitive  to 
the  touch.  The  os  uteri  is  also  soft,  and  if  there  have  been  endome- 
tritic  inflammations  it  may  be  irregular  in  outline  and  surrounded  by  an 
erosion,  while  there  is  also  a  discharge  from  it.  Bimanually,  the  uterus 
will  be  felt  displaced  to  either  side,  if  the  effusion  be  lateral,  and  if  sur- 
rounding the  uterus  there  will  be  the  '  board-like '  feeling  of  the  vaginal 
vault,  and  the  accompanying  difficulty  of  isolating  the  uterus  from  the 
peri-uterine  hard  effusion,  which  in  some  cases  may  be  mistaken  for  a 
fibroid  fining  the  pelvis.  Here  again  the  uterine  cavity  will  not  neces- 
sarily be  enlarged,  and  there  is  not  infrequently  considerable  displace- 
ment of  the  bladder.  By  the  recto-vaginal  examination  the  displaced 
adnexa  may  be  felt,  and  the  limits  of  the  effusion,  as  well  as  its  relation 
to  the  uterus,  determined. 

Pelvic  Tumours. — In  the  instance  of  pelvic  tumours,  occurring  either  in  the 
space  of  Douglas,  the  rectum,  vagina,  or  bladder,  the  cervix  uteri  and  os 
are  normal  in  size  and  to  the  touch,  but  the  cervix  is  displaced  propor- 
tionately to  the  size,  position,  and  direction  of  growth  of  the  tumour, 
leaving  it  still  movable  and  the  uterus  easily  disassociated  from  it  by  the 
bimanual  examination. 
For  further  hints  in  the  differentiation  of  pelvic  tumours  from  conditions 

in  which  there  may  be  ascent  of  the  uterus,  see  chapter  on  '  First  Steps  in 

Examination,'  and  those  on  the  diagnosis  of  the  fibro-myomata  and  ovarian 

systoma. 


*■  CHAPTER   XIV. 

UTERINE    DISPLACEMENTS  (continued;. 

Inversion  of  the  Uterus. 

By  inversion  of  the  uterus  we  simply  mean  a  turning  of  the  uterus 
inside  out.  It  is  partial  or  complete,  acute  or  chi'onic.  There  are 
two  stages  of  partial  inversion  (Crosse)  :  (1)  depression,  (2)  intro- 
version. The  fundus  is  received  into  the  cavity  of  the  uterus, 
ultimately  reaching  to  the  os  uteri ;  the  intruding  fundus  is  grasped 
by  the  uterus,  and  the  process  of  intussusception  is  continued  until 
the  extrusion  of  the  fundus  from  the  os  uteri  occurs.  Once  this 
has  happened,  the  protrusion  of  the  fundus  and  body  of  the  uterus 
from  the  os  uteri  may  continue  until  the  cervix  and  lips  of  the  os 
uteri  itself  are  inverted. 

Inversion  may  be  met  with  either  as  a  sudden  occurrence  or  as  a 
chronic  condition.  The  former  accident  is  more  fully  discussed  in 
works  on  '  Midwifery.' 

The  essential  element — as  it  always  is  the  predisposing  one — in 
inversion  is  an  atonic  state  of  the  uterine  parenchyma,  favouring 
relaxation  of  the  muscular  fibres.  This  leads  to  partial  prolapse 
of  a  portion  of  the  uterine  wall,  and  is  associated  with  an  irregular 
contraction  of  the  surrounding  muscular  tissue.  The  prolapsed 
portion  is  treated  by  the  uterus  as  a  foreign  body,  like  a  piece  of 
placenta,  or  the  hand  ;  it  excites  contractions  which  end  in  expulsion 
of  a  part  or  the  whole  of  the  fundus.  This  view  (Rokitansky)  is 
not  inconsistent  with  the  possible  and  occasional  origin  of  the 
inversion  at  the  cervix  uteri  (Taylor  and  Klebs),  which  latter  is 
inverted  and  protrudes  into  the  vagina. 

Causes. — Atony  of  the  uterus,  in  whole  or  part,  is  produced  by 
(1)  parturition,  (2)  tumours  and  polypi,  (3)  placental  adhesions, 
(4)  haemorrhage.  The  process  of  traction  of  the  uterine  wall  is  asso- 
ciated with  the  first  three  of  these ;  hi\imorrhage  is  a  consequence  of 
each  of  the  three.    If  there  be  general  relaxation  of  the  uterus,  such 


314 


DISEASES    OF   WOMEN. 


aa  exciting  cause  as  any  violent  exertion,  or  severe  coughing,  might 
be  sufficient  to  produce  a  slight  inversion  or  depression,  and  give  the 
first  impetus  to  the  morbid  process.  It  would  appear  that  inversion 
of  the  virgin  uterus  may  take  place  (Puzos,  Boyer,  Baudelocque, 
Langenbeck).     Goodell    believes   that    ectropion    of    the    cervical 


Fig.  227. — Ixveksiox  of  the  Utekus.     (Robert  Bakkes.) 

a,  vagina;  h  and  c,  inverted  uterus  incised  to  show  the  cavity;  e,f,  g,  ovaries, 
Fallopian  tubes,  and  round  ligaments;  h,  cervix  covered  by  peritoneum. 
Two-thirds  size,  after  Orosse,  in  Musee  Dupuytren. 

mucosa  may  occasionally  follow  the  general  relaxation  consequent 
upon  sterility,  and  masturbation  in  young  girls,  and  thus  start  the 
inversion  process. 

Aveliug  thus  classified  inversion  ; 

Automatic  or  \  -^^^^^^  ^f  inherent  muscular  contraction.     Placental  tumour. 

Fundal.       ) 

Systemic     "|Eesult  of  extraneous  abdominal  and  respiratory  muscular  con- 

(generally     \     tractions  when  there  is  inertia  of  the  body  and  relaxation  of 

Cervical).     J     the  os. 

Mechanical    1^^^^^   ^f  blows;  manual  compression;    abdominal  pressure 
(Propulsive)    f     ^^^^  viscera,  fluid,  or  gas ;  traction  exercised  on  or  by  cord 

or  , 

^  .     ,  or  tumour. 

Extractive).   J 


UTERINE  DISPLACEMENTS. 


315 


the  presence  of   a  tumour, 


Signs  and  Symptoms.— These  are 
generally  not  volu- 
minous, felt  in  the 
vagina,  simulating 
polypus,  attended  fre- 
quently with  haemor- 
rhage, either  constant 
or  periodical ;  bear- 
ing-down pains ;  pain 
occasionally  in  walk- 
ing ;  perhaps  rectal 
and  vesical  distress. 
Anfemia  is  a  com- 
mon attendant,  from 
the  associated  loss  of 
blood  and  general 
debility. 

Differential  Diag- 
nosis. —  The  main 
proofs  we  rely  on  that 
a  tumour  in  the 
vagina  is  an  inverted 
uterus  are  :    (1)  the 

presence  of  a  soft,  readily  bleeding  and  sensitive  tumour;  (2)  the 
absence  of  the  uterus  from  its  position  in  the  pelvis;  (3)  the  absence 


Fig. 


228.— Partial  Inversion  of  Uterus,  Second 
Degree.    (Bonts'et  and  Petit.) 


Fig.  229. — Inverted  Uterus. 
(Doyen.) 


Fig.  230. — Prolapsus  Uterus. 
(Schrceder.) 


316 


DISEASES   OF    WOMEN. 


of  the  normal  uterine  opening,  and  the  impossibility  of  passing  the 
uterine  sound  farther  than  the  neck  :  the  finger  feels  the  cervix  at 
the  summit  of  the  tumour,  perhaps  thinned  out  to  a  ring. 

In  Complete  Inversion.- — A  case  of  suspected  inversion  has  to  be 
differentiated  from  polypus  or  procidentia,  and  in  the  instance  of 
partial  inversion,  intra-uterine  fibroid.  Having  made  a  careful  digital 
examination  of  the  size  and  consistence  of  the  tumour,  we  explore 
it  through  the  rectum  and  detect  the  absence  of  the  uterus.  By 
conjoined  examination  we  confirm  this.  We  take  the  uterine  sound, 
and  find  it  arrested  at  the  neck  of  the  uterus,  round  which  we 
sweep  it :  it  may  pass  just  inside  the  cervix  for  the  extent  of  an 
inch  or  an  inch  and  a  half.  The  sound  is  now  passed  into  the 
bladder,  and  the  finger  into  the  rectum,  and  by  the  recto-vesical 
examination  the  fact  that  the  uterus  is  absent  is  ascertained. 

In  Partial  Inversion. — This  is  much  more  difiicult  to  diagnose. 
The  trouble  is  to  distinguish  it  from  an  intra-uterine  fibroid.     By 


Fig.  231.— Odtlixe  Dia-    Fig.  232.— Outline  Dia- 
gram OF  Complete  Ix-        gbam  of  Partial  Ix- 

VERSIOX.  version. 


Fig.  233.— Outline  Dia- 
gram OF  POLTPUS  at 
Summit  of  Uterine 
Cavity. 


the  conjoined  examination  we  may  detect  the  absence  of  the  fundus. 
On  passing  the  sound,  it  is  arrested  by  the  prolapsed  portion  of  the 
uterus,  which  is  sensitive.  In  the  fibroid  growth  the  uterus  is 
enlarged,  and  the  sound  passes  farther  than  in  the  normal  uterus, 
while  the  tumour  is  painless.  The  history  of  the  two  is  different ; 
the  fibroid  growth  is  slow— there  is  no  relation  to  parturition. 
Inversion  occurs,  as  a  rule,  suddenly,  and  the  uterus  is  sensitive. 
When  there  is  room  for  doubt,  the  cervix  should  be  fully  dilated 
and  a  digital  exploration  made. 

Prognosis. — This  must  always  be  given  with  reserve.  Even 
admitting,  says  Thomas,  the  undoubted  authenticity  of  the  cases 
reported,  spontaneous  reduction  must  be  regarded  only  as  a  curiosity, 


UTERINE  DISPLACEMENTS.  317 


and  not  as  a  process  to  be  anticipated.     The  patient  may  be  worn 
out  witli  pain  and  exhausted  by  haemorrhage. 

Treatment, — This  may  be  briefly  considered  under  three  heads  : 
(a)  palliative  ;   {V)  taxis  and  pressure  ;  (c)  operative. 

Palliative. — Palliative  treatment  is  hardly  to  be  considered  in 
the  face  of  modern  advance  in  the  treatment  of  inversion,  and  can 
only  be  justified  in  view  of  the  refusal  on  the  part  of  the  patient  to 
submit  to  interference  of  any  kind.  It  consists  of  strong  astringent 
preparations  of  alum,  tannin,  perchloride  and  persulphate  of  iron, 
matico,  hamamelis  ;  daily  injections  of  very  hot  water ;  ergot  given 
internally.  Aran,  in  very  bad  cases  where  amputation  was  contra- 
indicated,  used  the  Paquelin  cautery,  or  potassa  cum  calce,  to  the 
surface  of  the  mass.  In  this  manner,  when  the  uterine  mucous 
membrane  thickens  and  becomes  like  skin,  the  course  of  nature  is 
imitated. 

Taxis  and  Pressure. — This  must  in  very  old  cases  be  assisted  by 
the  local  application  of  cocaine,  in  the  form  of  ointment  and 
suppository.  The  vagina  is  previously  dilated  by  hydrostatic  bags, 
and  possibly  two  or  three  small  and  superficial  longitudinal  incisions 
through  the  tissue  of  the  cervical  ring.  But  the  great  danger  of 
the  employment  of  force  has  to  be  remembered  ;  the  vagina  may  be 
ruptured,  or  fatal  peritonitis  result.  '  A  small  hand,'  says  Thomas, 
'  a  cautious,  unexcitable  mind,  and  constant  vigilance,  during  all 
the  efibrts  by  taxis,  must  be  combined  with  thorough  knowledge  of 
the  subject.'  '  I  confess  that  I  should  prefer  to  trust  a  patient  in 
whom  I  felt  great  interest  rather  to  the  operation  of  abdominal 
section  (for  the  reduction  of  the  tumour),  than  to  that  of  prolonged 
taxis  at  the  hands  of  a  rough,  unintelligent  and  inexperienced 
surgeon.'  If  this  be  his  deliberate  opinion,  after  a  personal  expe- 
rience of  nine  cases  of  inversion,  it  is  not  necessary  to  dwell  on  the 
care  and  caution  with  which  attempts  at  reduction  of  the  chronically 
inverted  uterus  must  be  made. 

The  ordinary  practitioner  is  not  likely  to  attempt  this  operation 
without  mature  consideration  and  careful  consultation.  The  principal 
obstacle  to  be  overcome  is  the  constriction  of  the  cervical  ring, 
through  which  has  to  be  returned  the  enlarged  and  hardened 
uterine  body. 

Aran,  Marion  Sims,  Robert  Barnes,  and  Matthews  Duncan  tried 
to  overcome  the  difficulty  by  making  multiple  incisions  into  the 
cervix,  and,  more  recently.  Hirst  successfully  adopted  this  plan  in  a 
case  of  three  months'  duration. 


318 


DISEASES   OF    WOMEN. 


In  practice  it  would  be  far  better  to  trust  to  continous  pressure  than  run 
the  risk  of  any  dangerous  force  or  prolonged  manipulation.  Before  an 
attempt  at  reduction  be  made,  the  rectum  and  bladder  should  be  emptied, 
and  an  anaesthetic  administered.  The  nails  of  the  operator's  hands  are  care- 
fully pared,  and  the  operating  hand  is  well  oiled.     One  hand  must  be  laid  on 

the  abdomen,  over  the  situation  of  the  ring 
of  the  opposing  cervix.  With  this  counter- 
pressure  is  maintained  against  the  hand  ope- 
rating in  the  vagina.  McClintock's  axiom  is 
to  be  remembered,  of  returning  first  the  part 
which  has  inverted  last.  Emmet's  plan  is 
then  adopted.  The  patient  is  placed  in  the 
lithotomy  position;  the  inverted  uterus  is 
grasped  between  the  finger  and  thumb  of  the 
right  hand ;  the  fingers  of  the  left  hand  main- 
tain steady  counter-pressure  on  the  abdomen. 
The  inverted  fundus  is  pushed  steadily  up- 
wards with  the  right  hand,  while  the  fingers 
are  used  to  dilate  the  cervix.  If  the  ciase  be 
comparatively  recent,  the  plan  of  dimpling 
the  fundus  with  the  fingers,  and  forcing  the 
indented  wedge  thus  formed  into  the  cervical  ring,  and  so  overcoming  the 
resistance,  may  be  tried.  Repositors  of  different  kinds  have  been  used.  If 
the  cup-repositor  of  White  be  used,  the  cup  is  steadied  with  the  right  hand 
against  the  fundus,  and  the  force  is  appHed  by  means  of  a  spiral  spring,  which 
the  operator  presses  against  the  chest,  counter-pressure  being  maintained  by 
the  left  hand  over  the  cervix  on  the  abdomen. 


Fig.  234. — Eeduction  of  In- 
verted Utekus.     (Emmet.) 


Pressure. — If  from  the  duration  of  the  case,  or  from  the  experience 
of  moderate  manual  efforts  at  reduction,  we  deem  it  inadvisable  to 
proceed  with  the  taxis,  continuous  elastic  pressure  may  be  tried. 
Aveling,  Robert  Barnes,  and  Braxton  Hicks  were  prominent  advo- 
cates for  continuous  pressure.  The  stem  and  cup  of  the  former 
may  be  used  for  the  purpose.  The  curved  stem  has  at  one  extremity 
a  cup-shaped  disc  of  rubber,  or  a  hollow  cup  of  caoutchouc.  The 
other  end  of  the  stem  has  four  strong  rubber  bands,  attached  to  the 
abdominal  belts,  which  serve  to  maintain  the  pressure  on  the  fundus. 
By  tightening  the  back  or  front  bands,  the  direction  of  the  pressure 
is  changed.  Counter-pressure  is  secured  by  an  abdominal  pad  placed 
under  a  broad  flannel  roller.  The  position  of  the  cup  and  the  direc- 
tion of  the  stem  are  watched  from  day  to  day.  It  is  well  to  pack 
the  vagina  carefully,  round  the  inverted  uterus,  with  a  tampon  of 
antiseptic  wool.  Robert  Barnes  advises  periodical  attempts  at 
reduction  with  the  hand,  under  chloroform,  when  the  cup  is  removed. 
Should  the  continuous  pressure  give  rise  to  pain,  or  should  there  be 


VTEnrXE   r>f.<=!PLACEMENT.9.  319 


any  sloughing,  it  must  bo  relaxed,  and  an  interval  of  rest  permitted. 
Its  tolerance  may  be  assisted  by  the  administration  of  bromide  of 
potassium  and  chloral.  The  application  should  be  made  between 
the  menstrual  periods.  Should  a  tumour  complicate,  or  be  the 
cause  of,  an  inversion,  we  must  remove  the  growth,  and  then 
endeavour  to  rectify  the  inversion. 

Xoeggerath's  method  consists  in  the  indentation  of  one  corner  first,  assisted 
by  counter-pressure  over  the  ring  of  inversion  from  above  the  pubes. 

As  regards  the  time  after  the  occmTcnce  of  the  inversion  at  which  success- 
ful reposition  may  be  attempted,  this  varies  ;  Aveling's  opinion  was  that  every 
case  of  chronic  invei*sion  of  the  uterus  was  curable. 

Fancourt  Barnes  recorded  a  case  of  inversion  of  the  uterus,  of  four  months' 
standing,  successfully  restored  in  eight  hom-s  by  means  of  Aveling's  repositor. 

Jaggard  has  recorded  a  case  of  twenty  months'  standing  reduced,  after 
thirty-three  daySj  by  colpeurysis. 

Aveling  cured  eleven  cases  of  chronic  inversion  by  his  sigmoid  repositor. 
Each  case  took  on  an  average  40  hours  for  its  cure — the  longest  time  occupied 
being  54^  hours,  and  the  shortest  9  hours.  The  following  are  Aveling's 
instructions  for  its  use  : — 

Directions  for  using  Aveling's  Sigmoid  Repositor. 

'  Having  diagnosed  inversion,  determine  by  touch  the  size  of  the  fundus, 
and  select  a  cup  of  proportionate  size.  It  should  be  in  diameter  slightly  less 
than  that  of  the  fundus.  Next  apply  the  belt  round  the  waist,  and  then  the 
braces  over  the  shoidders,  and  fasten  them  by  safety-pins  to  the  belt.  This 
should  be  done  in  such  a  way  as  to  leave  room  to  pass  the  tapes,  to  which 
the  rings  are  attached,  between  the  pin  of  the  safety-pin  and  the  belt.  Now 
the  cup  of  the  repositor  should  be  applied  to  the  fundus  uteri,  and  held 
firmly  in  position  by  an  assistant  while  the  rings  are  adjusted,  two  being 
taken  in  front  and  two  behind.  The  ends  of  the  tapes  should  next  be  passed 
between  the  safety-pins  and  the  belt,  parts  of  the  tapes  drawn  through,  and  a 
knot  made  at  the  ends  to  prevent  them  slipping  back.  Tension  may  be  lastly 
exerted  by  drawing  the  tapes  up  through  the  pins  and  fastening  them  at  any 
point  by  tying  a  loop.  This  loop  can  be  easily  pulled  out  and  retied,  should 
more  or  less  tension  be  required.  Care  must  be  taken  to  have  the  tension 
equally  distributed;  for  if  the  front  bands  be  tighter  than  the  back,  there 
arises  the  risk  of  the  cup  being  slipped  back  off"  the  fundus ;  and  the  opposite 
may  occur  if  the  posterior  bands  be  tighter  than  the  front.  The  indiarubber 
bands  passing  to  the  front  should  be  carefully  laid  outside  the  labia  and 
packed  with  cotton-wool.  If  the  patient  be  restless  or  complain  of  pain, 
raoi-phia  may  be  administered.  She  should  be  carefidly  watched,  and  the 
urine  drawn  by  catheter  when  necessary.  It  is  difficult  to  lay  down  any  rule 
for  tightening  and  loosening  the  tapes.  This  will  be  determined  by  the  prac- 
titioner, who  must  judge  by  the  existing  tension,  and  the  tolerance  of  it  by 
the  patient.  In  my  last  case,  re-inversion  was  accomplished  without  the 
tapes  being  touched  after  their  first  adjustment.' 


320 


DISEASES   OF   W03IEF. 


'  Reduction  takes  place  hy  the  cervical  method.  Pressing  on  the  fundus 
causes  counter  vaginal  traction  on  the  cervix,  making  it  unroll  gradually  until 
the  inner  os  is  reached,  where  a  little  delay  is  caused  by  its  being  less  dilatable. 
When  this  point  is  passed,  the  body  of  the  uterus  soon  opens,  and  admits  the 
cup.  The  last  step  must  occur  rather  suddenly,  for  all  patients  say  they  feel 
that  something  has  "  given  way,"  and  comparative  comfort  is  the  result, 

'  When  the  inversion  has  been  reduced,  the  sooner  the  cup  is  withdrawn 
the  better,  for  the  cervix  immediately  begins  to  close  round  the  metal  stem, 


Fig.  235. — White's  Cup  Eepositoe. 
(Thomas.) 


Fig.  236.-^Sigmoid  Repositor. 


and  the  cup  becomes  firmly  grasped  in  the  uterine  cavity.  Tlie  easiest  way 
of  removing  the  cup  is  to  tilt  it  on  end,  and  bring  it  through  the  os  as  you 
would  a  button  through  a  button-hole.  If  it  should  have  been  long  retained, 
an  anaesthetic  will  assist.  When  the  cup  has  been  removed,  pass  a  thick 
sound  into  the  uterus,  and,  by  pressing  the  point  of  it  forward,  the  rounded 
fundus  will  be  felt  through  the  abdominal  walls.  Being  satisfied  that  com- 
plete re-inversion  has  taken  place,  syringe  out  the  uterine  cavity  with  iodme 
water  at  120°  Fahr.,  which  will  cleanse  its  surface  and  make  the  whole  organ 
contract.' 

Elastic  Ligature. — Perrier  amputated  the  cervix  by  means  of  the 
elastic  ligature,  using  a  curved  rubber  forceps  to  draw  the  uterus 
well  down.  He  surrounded  the  fundus  with  a  ligature  of  strong 
silk,  and  over  this  an  encircling  ring  of  elastic  rubber,  both  being 
tightened  by  means  of  a  cog-handled  holder.  By  this  means  the 
ligature,  after  the  uterus  was  returned  into  the  vagina,  was  slowly 


UTERINE  J>ISPLA(EMEXTfi:.  321 


tightened  until  it  separated,  from  the  ninth  to  the  fourteenth  day. 
The  strictest  asepsis  was  enjoined. 

Kaltenbach,  having  secured  the  fundus  by  silk  and  elastic  liga- 
tures, amputated  below  these. 

Vaginal  Amputation  of  the  Uterus. — The  surface  of  the  tumour 
and  the  vagina  having  been  thoroughly  cleansed,  the  uterus  is 
drawn  down,  and  the  neck  of  the  sac  is  brought  well  within 
reach.  Two  flaps  are  cut,  beginning  at  the  neck  of  the  inverted 
uterus,  anterior  and  posterior.  Three  or  four  strong  gut  or  silk 
ligatures  are  then  carried  thi'ough  the  stump  from  before  back- 
wards before  the  pei'itoneum  is  opened  in  front.  The  peritoneal 
opening  is  enlarged,  and  the  uterine  vessels  are  secured  at  either 
side.  The  uterine  ligatures  serve  to  prevent  the  inversion  of  the 
stump.  These  are  finally  tied,  and  the  flaps  carefully  approximated. 
The  vagina  is  dressed  in  the  usual  manner,  and  the  ligatures  can  be 
removed  in  from  ten  to  twelve  days. 

Pan-Hysterectomy. — Vaginal  pan-hysterectomy  may  be  performed 
much  in  the  usual  manner,  care  being  taken  not  to  injure  the  bladder, 
which  is  not  contained  in  the  sac,  as  is  frequently  the  case  in 
prolapse. 

G-aillard  Thomas's  Operation. — Gaillard  Thomas  first  conceived 
and  carried  into  successful  execution  the  design  of  restoring  the 
inverted  fundus  by  opening  the  abdomen,  dilating  the  contracting 
ring  by  a  steel  dilator,  and  applying  pressure  on  the  fundus  from 
the  vagina.     By  other  operators  (Haultain)  the  ring  was  incised. 

Eeuben  Peterson,  in  a  review  of  the  entire  subject,*  states  that  he  has 
traced  out  the  result  in  fifteen  cases  in  which  Thomas'  operation,  or  some 
modification  of  it,  was  performed.  Of  these,  eight  were  successful,  seven 
were  complete  failures,  in  one  the  result  being  fatal,  and  in  four  the  uterus 
having  to  be  amputated.  Peterson  also  shows  that  to  B.  B.  Brown  is  due 
the  conception  of  the  central  idea  of  incising  the  posterior  uterine  wall  in 
order  to  dilate  the  encircling  ring  by  means  of  Sims'  and  Hank's  dilators. 
Polk  also  advocated  incision  through  the  utero-vaginal  junction  in  order  to 
divide  the  constriction,  advising  the  further  free  division  of  the  cervix  if 
necessary. 

Klistner's  Operation. — The  following  are  the  steps  of  this  mode 
of  reposition : — The  pouch  of  Douglas  is  opened  transversely.  The 
finger  is  carried  through  the  opening  into  the  inverted  uterine  sac, 
and  any  adhesions  are  separated.     A  longitudinal  incision  is  now 

*  Amer.  Gyn.,  June,  1903. 


322  DISEASES   OF    WOMEN. 

made  through  the  posterior  wall  of  the  uterus  in  the  middle  line, 
from  two  centimetres  below  the  inverted  fundus  to  two  centimetres 
above  the  external  os,  right  down  to  the  peritoneum.  The  uterus 
is  next  re-inverted  by  the  aid  of  the  index  finger  in  the  pouch  of 
Douglas,  which  steadies  the  funnel,  while  thumb  pressure  is  made 
on  the  fundus  at  the  same  time.  The  uterine  incision  is  closed  by 
two  layers  of  sutures,  the  pouch  of  Douglas  is  also  closed,  and  the 
operation  is  complete. 

Dtihrssen's  Operation. 

Duhrssen  and  Kehrer  modified  Kiistner's  operation  by  dividing 
the  peritoneum  in  front  of  the  uterus,  between  it  and  the  bladder, 
the  anterior  wall  being  incised.  Furneaux  Jordan  reduced  an 
inverted  uterus,  which  filled  the  vagina,  by  this  operation,  by  means 
of  which,  he  says,  it  is  easier  to  efiect  reduction,  as  it  is  difiicult  to 
reach  the  pouch  of  Douglas  in  these  extreme  cases.*  The  operation 
is  as  follows  : — 

The  uterus  is  pressed  lightly  backwards  with  the  fingers  of  the 
left  hand,  and  the  vaginal  mucous  membrane  is  divided  as  in  col- 
potoray.  The  bladder  is  hooked  upwards  and  forwards  by  fine 
vulsellum  forceps,  and  the  peritoneum  is  opened  in  the  usual  manner. 
The  index  finger  is  directed  to  the  opening  of  the  cup  formed  by 
the  inversion.  Here  is  the  source  of  difiiculty  in  replacement.  The 
OS  and  cervix  are  now  divided  with  scissors  in  the  anterior  median 
line,  and  the  incision  may  have  to  be  extended  considerably  along 
the  anterior  middle  line  of  the  uterus.  The  reduction  is  now 
effected,  and  the  incision  is  closed  with  fine  silk  or  gut.  A  small 
iodoform  drain  may  be  left  in  the  utero-vesical  povich. 

Piccoli's  Operation. 

In  1894  Piccoli  formulated  an  operation,  the  steps  of  which  are 
briefly  as  follows : — 

Thorough  asepsis  having  been  secured,  the  uterus  is  lowered 
either  by  an  elastic  ligature  or,  as  Duret  proposes,  a  Museux'  for- 
ceps. It  is  then  curetted,  and  next  a  transverse  incision  is  made 
in  the  cul-de-sac  of  Douglas,  reaching,  if  necessary  (as  done  by  Mori- 
sani,  who  was  the  first  to  perform  Piccoli's  operation  in  1896),  as 

*  Birmingham  Medical  Review,  Jan.,  1897 :  '  Treatment  of  Inversion  of  the 
Uteru3— a  New  Operation.     Furneaux  Jordan.' 


UTEHLSE    lUSPLACEMENTS.  32H 


far  as  the  sacral  ligaments.  If  reduction  cannot  now  be  eflfected, 
the  entire  thickness  of  the  posterior  wall  of  the  uterus,  from  the 
external  os  to  the  fundus,  is  incised,  and  reduction  is  effected  by 
doubling  the  uterus  back  upon  itself  from  the  incised  wall.  The 
mucosa  is  thus  brought  inside,  and  the  peritoneal  covering  outside, 
while  the  incision  appears  in  front  instead  of  behind.  The  incision 
is  then  closed,  and  the  uterus  is  replaced  in  the  abdominal  cavity 
by  raising  it  through  the  opening  in  the  pouch  of  Douglas,  which  is 
now  sutured.  If  haemorrhage  be  uncontrollable,  hysterectomy  must 
be  performed. 

Peterson's  Operation. 

Peterson's  own  operation,  which  was  successful,  consisted  of  the  following 
steps  : — 

(1)  Drawing  down  the  inverted  fundus  with  vulsella,  while  the  anterior 
vaginal  mucosa  was  rendered  tense  by  being  pulled  upwards  above  the  anterior 
lip  of  the  inversion  cup.     (2)  A  transverse  incision  of  two  inches  and  a  half 
close  to  the  cervix  through  the  vaginal  mucosa,  opening  the  utero-vesical 
pouch.    (3)  Exposure  and  division  of  the  cervix  by  an  incision  carried  upwards 
in  the  anterior  median  line  to  within  one-third  of  an  inch  of  the  fundus. 
^4)  Eeduction  of  the  inversion,  with  the  adoption  of  John  Taylor's  suggestion 
of  removal  of  a  wedge-shaped  portion  of  the  bulging  uterine  wall  so  as  to 
enable  the  retracted  peritoneal  edges  to  be  brought  together.     (5)  Closure  of 
the  uterine  incision  by  a  continuous  catgut  suture.     Lastly,  the  passage  of  a 
catgut  suture  round  the  uterine  end  of  each  round  ligament,  the  ends  being 
passed  through  the  anterior  vaginal  wall,  and  so  tied  that  the  line  of  incision 
was  brought  well  up  against  the  vesical  peritoneum.    Two  small  gauze  drains 
were  left,  one  between  the  bladder  and  uterus,  and  the  other  in  the  uterine 
cavity. 

Peterson  strongly  advises  the  vaginal  rather  than  the  abdominal  route  in 
operating.     He  divides  the  methods  under  these  heads : — 
Partial  posterior  colpo-hysterotomy  (Kiistner's  operation)  ; 
Complete  posterior  colpo-hysterotomy  (Piccoli's  operation)  ; 
Partial  anterior  colpo-hysterotomy  (Kehrer's  operation ;  incision  through 
the  anterior  uterine  wall  from  the  external  os  to  the  centre  of  the  fundus)  ; 

Complete    anterior    colpo-hysterotomy ;    incision    through    the    anterior 
uterine  wall  from  the  external  os  to  the  fundus. 

Of  twenty-six  cases  by  these  different  methods,  there  were  three  failures 
and  no  death.  With  regard  to  the  difficulty  of  dilating  the  ring  from  the 
abdominal  side,  Peterson  dwells  on  the  unyielding  nature  of  the  connective 
tissue  which  is  found  in  these  cases  in  the  uterine  fundus,  and  also  on  the 
greater  shock  involved  by  coeliotomy.  He  quotes  Spinelli's  argument  in 
favour  of  anterior  colpotom}',  that  there  is  a  greater  likelihood  of  adhesions 
forming  from  the  posterior  incision,  and  urges  the  advantages  of  John  Taylor's 
suggestion  of  the  removal  of  a  wedge-slmped  piece  from  either  uterine  wall, 
so  as  to  bring  the  muscular  and  peritoneal  layers  into  accui'ate  apposition. 


Fig.  237. — Bhuwing  SErTrnwi,  A'ikw  of  Cioiplkte  Ixversiox  of  the  Uterus. 

(Hafltain-.) 


Fig. 


'a. — ^'^■:^^■ 


;ame,  shq-wixg  the  Peltio  Catiiy  from  above. 
(Hafltaix.) 
These  figures  are  representative  of  a  case  in  which  Haultain  reduced  the 
uterus  by  the  abdominal  route,  after  incision  of  the  posterior  uterine  wall  from 
within  an  inch  and  a  half  of  the  fundus  to  half  an  inch  above  the  vagina,  the 
incision  being  closed  after  reduction  by  catgut  sutures,  deep  and  superficial. 
Haultain  argues  that  by  tlie  abdominal  route  the  uterine  incision  is  reduced  to 
a  minimum.  We  have  the  assistance  of  traction  on  the  broad  and  round  liga- 
ments, and  can  more  efficiently  close  the  incision  and  control  haemorrhage.  {Brit. 
Med.  Jour.,  Oct.  5^  1901.) 


UTERINE  DISPLACEMENTS.  325 


Reviewing  all  the  evidence  which  has  accumulated  within  recent 
years,  and  the  results  of  the  various  operative  procedures  which 
have  been  devised  for  the  reduction  of  the  inverted  fundus,  we  are 
irresistibly  led  to  the  conclusion  that  the  older  methods  of  pressure 
and  taxis  will  be  abandoned  in  favour  of  reposition  by  an  operative 
procedure  indicated  in  its  extent  and  nature  by  the  degree  and 
duration  of  the  inversion. 


CHAPTER   XV. 

INFLAMMATION    OF   THE    UTERINE   TISSUES- 
ACUTE   AND    CHRONIC. 

H"EPEEiEMiA  (active  and  passive). 

Acute — Metritis  and  Endometritis  (cervical  and  corporeal). 

Gonorrhoea. 
Chronic — (a)  Endometritis  (cervical  and  corporeal). 

(6)  Chronic  Hyperplasia  (syn.  Chronic  Parenchymatous 
Metritis). 

(c)  Subinvolution. 

(d)  Catarrhal  Inflammation  of  Cervix. 

(e)  Granular  Degeneration  of  Cervix. 

This  is  a  simple  clinical  classification,  and  appears  to  be  the 
best  for  clinical  purposes.  The  pathological  sources  of  metritis  have 
to  be  remembered,  and  these  are  mentioned  incidentally  in  treating 
of  the  causation  of  the  various  acute  and  chronic  forms  of  inflamma- 
tion of  the  cervical  and  corporeal  canal.  We  find  such  primary 
causes  of  metritis  in — 

(1)  Puerperal  septic  processes,  initiated  by  pathogenic  organisms 
(pyogenes  and  saprophytes) ;  chronic  mucopurulent  discharges 
associated  with  similar  germs  (streptococcus  and  staphylococcus) ; 
traumatic  inflammatory  processes  which  follow  on  wounds  of  the 
cervix,  lacerations,  etc. 

(2)  Gonorrhoeal  inflammation,  caused  by  the  contact  of  gonorfhceal 
virus  {gonococcus  —  merismopedia  gonorrhoea). 

(3)  Tubercular  inflammation,  tubercle  bacillus  with  or  without 
evidences  of  tubercle  elsewhere  in  the  body. 

(4)  Syphilis  and  syphilitic  new  growths ;  secondary  deposits  ;  de- 
generation in  the  parenchyma  or  mucous  membrane. 

Hypersemia. — The  vascular  system  of  the  uterus  is  subject  to 
considerable  fluctuations  in  its  blood-supply.  This  we  should  expect, 
not   alone    from    its    anatomical    peculiarities    in   the   distribution 


INFLAMM Alios  OF  UTERINE  TISSUES— ACUTE  AXD  CllflOXIC.    327 


of  the  uterine  vessels  and  the  erectile  muscular  tissue  which 
surrounds  them,  but  also  from  the  influences  to  which  the  uterus 
is  subject  periodically,  such  as  menstruation,  coitus,  ovarian  ex- 
citement, morbid  growths,  displacements,  peri-uterine  inflammations. 
Nor  can  we  ignore,  in  the  uterus  as  elsewhere,  the  influence  exerted 
on  the  arteries  by  reflex  excitations.  Hardly  otherwise  can  we 
account  for  inflammatory  mischief  arising  from  some  slight  exposure 
to  cold,  or,  in  some  instances,  fioui  the  careful  passage  of  the  uterine 
sound  and  the  uterine  disturbance  that  follows  mental  shock. 

Symptoms  and  Physical  Signs. — Such  sensitiveness  and  tender- 
ness are  present  in  these  cases  as  we  might  anticipate  would  be  from 
a  slightly  swollen  and  turgid  womb.  There  often  is  an  exaggeration 
of  the  natural  secretion,  and  a  tendency  to  menorrhagia,  or  some 
occasional  irregularity  of  the  periods,  and  metrorrhagia  On 
examination  we  may  detect  a  congenital  defect,  predisposing  to 
stenosis  and  dysmenorrhoea,  or  a  uterine  displacement,  or  small 
fibroid.  The  patient  complains  of  pain  in  the  back,  and  about  the 
pelvis,  and  inability  to  walk  much  or  to  stand.  Yery  often  the 
sufferers  are  women  who  have  to  stand  a  great  deal,  or  are  occupied 
in  some  sedentary  work.  They  may  be  dyspeptic,  and  coincidentally 
we  may  discover  cardiac  or  renal  mischief,  or  functional  cardiac 
murmurs,  and  find  the  urine  of  low  specific  gravity. 

Treatment. — Under  this  head  I  include  general  hygienic  measures  ; 
such  rest  as  can  be  obtained ;  avoidance  of  coitus ;  change  of  air  : 
the  warm  vaginal  douche ;  local  depletion ;  the  use  of  Kreuznach 
and  Kissingen  waters ;  those  of  Woodhall  Spa  in  Lincolnshire, 
and  Salsomaggiore  ;  the  bromides  of  potassium  and  ammonia  ;  the 
combination,  already  recommended,  of  ergotine,  quinine,  and  lupu- 
line ;  the  glycerine,  or  ichthyol  (5  per  cent.)  and  glycerine,  tampon, 
worn  at  night,  and  the  extract  of  hydrastis  canadensis,  both  given 
internally  and  applied  as  a  tampon.  Alkaline  and  iodized  baths 
are  of  service,  taken  with  a  bath  speculum.  The  bowels  should  be 
regulated  by  aperients,  saline  waters,  and  occasional  enemata. 

Passive  Hyperaemia, — If  we  do  not  see  the  case  in  the  earlier 
stage  of  hyperaemia,  there  is  very  often  a  protracted  history,  and 
the  general  health  has  been  for  some  time  afiected.  The  causes 
enumerated  in  bringing  about  active  hyperemia  continue  in 
operation.  It  is  this  condition  of  uterus  which,  when  persistent, 
leads  to  general  hypertrophy  of  the  uterine  tissues,  and  even  to 
chronic  hyperplasia.  The  same  indications  for  treatment  exist  as 
in  the   active   state.     We  must  endeavour  to  correct  any  general 


328  DISEASES   OF    WOMEN. 


or  constitutional  fault,  while  we  control  local  congestion  and  subdue 
irritation. 

Acute  Metritis  and  Endometritis. — For  clinical  purposes  we 
may  define  this  state  as  that  of  acute  inflammation  of  the  uterine 
parenchyma  and  the  mucous  membrane  of  the  uterine  canal. 
"While  we  cannot  separate  pathologically  the  inflammation  which 
attacks  the  muscular  tissue  of  the  uterus  and  its  peritoneal  covering 
from  that  which  involves  its  mucous  membrane,  both  being  generally 
associated  and  intercurrent,  still,  this  division  into  acute  and  chronic 
metritis  and  endometritis  is  an  old  practical  distinction,  which  for 
clinical  purposes  it  is  as  well  to  preserve.  Most  frequently  the 
inflammation  commences  in  the  endometrium,  and  spreads  to  the 
muscular  structure  and  cellular  elements.  On  the  other  hand, 
the  attack  may  begin  in  the  peri-uterine  cellular  tissue,  or  the 
abdominal  or  uterine  peritoneum.  In  such  a  manual  as  this  it  is 
better  to  take  these  associated  conditions  together,  and  discuss 
them  at  the  same  time. 

Causation. — This  will  be  traced  to  wounds ;  injury  ;  any  shocks 
transmitted  to  the  uterus ;  operations ;  cold  caught  during  a 
menstrual  period  ;  gonorrhoeal  infection ;  septic  infection ;  puer- 
peral sepsis ;  intra-uterine  medication ;  the  use  of  stem-pessaries  or 
the  uterine  sound  ;  vaginitis. 

Symptoms  and  Physical  Signs. — Rigors  ;  high  temperature  ;  pain 
and  tenderness  in  the  hypogastric  region  ;  sense  of  fulness  in  the 
vagina,  accompanied  by  heat  and  sensitiveness ;  absence  of  the 
vaginal  secretion ;  viscid  discharge  from  the  uterus,  changing  to 
purulent — this  discharge  is  at  times  acrid  and  irritating  to  the 
skin  of  the  vulva.  On  digital  examination  the  uterus  is  found 
enlarged  and  very  sensitive;  the  lips  of  the  os  uteri  have  a 
tendency  to  gape.  With  the  spepulum  the  cervix  and  os  uteri 
appear  swollen  and  oedematous ;  the  latter  may  be  blocked  with 
discharge,  which  varies  in  its  nature  according  to  the  cause  of  the 
metritis. 

Septic  metritis — in  its  marked  preliminary  pyrexial  symptoms, 
the  great  pain,  the  accompanying  peritoneal  mischief,  and  the 
history  of  a  definite  cause,  as  a  recent  operation,  injury,  or 
septic  contagion — is  not  likely,  with  the  exercise  of  care,  to  be 
confounded  with  any  other  affection.  The  approach  of  pelvic  or 
general  peritonitis  is  marked  by  varying  degrees  of  immobility  of 
the  uterus,  abdominal  tenderness,  and  tympanites.  I  do  not  believe 
in  any  such  affection  as  uncomplicated  metritis.     I  have  never  seen 


INFLAMMATION  OF  UTERINE  TISSUES— ACUTE  AND  CHRONIC.    329 

a  case  of  metritis  run  its  course  without  some  degree  of  pelvic 
peritonitis,  perimetritis,  salpingitis,  or  endometritis  accompanying  it. 

Diagnosis. — If  with  the  foregoing  symptoms  we  find,  by  digital 
examination  and  the  bimanual  method,  that  the  uterus  is  enlarged 
and  sensitive,  while  the  vagina  is  hot  or  swollen,  we  can  have  no 
doubt  of  the  nature  of  the  affection. 

Prognosis. — This   must  always   be  cautiously   expressed  ;    much 
will  depend  on  the  exciting  cause  of  the  inflammation  and  the  stage 
at  which  we  see  it.     Should  the  inflamma- 
tion end  in  abscess,  peritonitis,  or  septicse-       ^^  ^J 
mia,  the    issue   may   prove    rapidly   fatal.         |                    11    ^\ 
On  the  other    hand,   if    the  inflammation        /                   u  \ 
remain  localized,  and  yield  to  active  treat-      |           ,<^rr^         m 
ment,  it  may  terminate  in  a  few  days,  or      i        /^^^^^     ^ 
it  may  pass  into  a  chronic  form,  leaving     ^^   Vv^^^mllJ    ^^ 
the  patient  with  an  enlarged    (parenchy-    I'  ^^^^^^^^-^  .^k 
raatous)  uterus  and  chronic  endometritis.    I         •'^^^^^  ^ 
It   is    well-nigh  impossible    to  diagnose    a   j       f      ^^F  m 
metritic  abscess.     It  is  necessary  to  insist    !      j            Mf  m 
on  the  danger  of  using  the  uterine  sound    ';     j           %  |  I 
in  any  case  of  acute  inflammation  of  the          1            |    \                / 
uterus  or  its  peritoneal  connections.        ^        Fig.    238.  -  Leiter's   Tem- 

Treatment. — In    acute    septic    metritis  perature  Coil. 

warm    compresses    should    be    used,    and 

spongiopiline,  sprinkled  with  laudanum  and  belladonna,  applied 
over  the  uterus  ;  leeches  may  be  applied  (eight  to  twelve)  over 
the  hypogastric  region,  close  to  the  pubes.  A  thin  linseed  poultice, 
covered  v/ith  oiled  silk,  or  a  mild  turpentine  and  laudanum  appli- 
cation, is  laid  over  the  lower  part  of  the  abdomen,  if  there  be 
tympanites.  A  lanolated  cream  of  oleate  of  mercury  and  morphia 
(5  per  cent.)  with  extract  of  belladonna,  spread  on  a  piece  of  Knen, 
and  laid  on  the  abdomen,  under  the  moist  compress  or  spongio- 
piline, will  be  found  of  use.  A  Leiter's  temperature-regulator  may 
be  placed  over  the  pubes  (Fig.  238).  Aveling's  coil  of  the  same 
tubing,  which  fits  into  a  cup  and  stem,  and  can  be  worn  in  the 
vagina,  is  an  ingenious  application  of  Leiter's  plan.  The  most 
efiicacious  of  all  means  of  cutting  short  the  inflammatory  process 
is  the  application  of  an  ice  poultice  or  ice-bag  over  the  hypo- 
gastrium.  The  medicines  we  rely  on  are  opium,  half-grain  to 
one-grain  doses  every  third  or  fourth  hour  ;  quinine,  either  alone  or 
combined  with  the  opium  ;  phenacetin  or  antipyrin  can  be  tried  as 


330  DISEASES    OF   WOMEN. 

anti-pyretics.  The  patient  must  be  fed  on  liquid  nourishment,  such  as 
milk,  chicken-broth,  and  beef -tea.  Alcohol  should  be  administered 
according  to  the  patient's  strength,  and  its  effects  on  the  pulse  and 
tongue  watched.  In  the  mean  time,  the  vagina  is  douched  out 
occasionally  with  perchloride  of  mercury  solution  (1  in  5000),  or 
formalin  (1  in  2000). 

Curettage. — Curettage  and  drainage  are  specially  indicated  in 
some  forms  of  metritis.  By  these  steps  the  uterine  isthmus  is 
enlarged  and  freed  from  obstruction,  the  flow  between  the  Fallo- 
pian tube  and  uterus  is  increased,  muscular  contractility  in  the 
tube  and  uterus  is  excited,  congestion  of  the  pelvic  organs  is 
lessened,  and  local  sterilization  of  the  uterine  cavity  by  antisepsis 
is  permitted.  The  decision,  however,  to  curette  the  uterus  will 
depend  in  great  part  on  the  nature  of  the  inflammation. 

If  the  metritis  be  due  to  intra-uterine  causes,  such  as  fungous  endometritis, 
chronic  purulent  endometritis,  retained  products  of  conception,  intra-utevine 
growths,  or  remains  of  operative  interferences,  it  is  my  practice  to  curette  in  the 
manner  already  described,  and  I  have  never  had  any  cause  to  regi'et  my  decision.* 

The  arrest  of  septic  dissemination  and  absorption  are  thus  secured,  while 
the  safety  of  future  operative  procedures  on  the  adnexa  is  increased.  '  A 
primary  coeliotomy  when  curettage  is  indicated  in  a  case  of  acute  salpingitis 
and  peritonitis,'  says  the  writer  in  Baldy's  '  System  of  Gynaecology,'  '  stamps 
a  man  as  blind  to  reason  and  to  the  work  of  other  men,  and  as  willing  to 
open  a  fellow-being's  abdomen  rashly  and  unnecessarily.' 

The  practice  of  the  gynsecology  of  to-day,  in  all  cases  of  septic  peri- 
tonitis, puerperal  and  other,  is  to  discountenance  the  old  methods 
of  inaction,  and  to  encourage  the  plan  of  timely  local  treatment 
of  the  source  of  the  infection,  in  the  endometrium,  by  curettage. 

In  all  cases  of  acute  uterine  inflammation,  the  administration  of 
a  saline  in  the  early  stages  is  of  service.  Liquor  ammonise  acetatis, 
with  sweet  spirits  of  nitre ;  bicarbonate  and  citrate  of  potash ;  the 
saline  mixture  of  sulphate  of  magnesia  in  infusion  of  roses,  are 
perhaps  the  simplest  and  most  useful.  If  the  bowel  be  costive  and 
the  tongue  coated,  a  few  grains  of  calomel  at  night,  followed  by  a 
saline  aperient  in  the  morning,  will  benefit. 

If  the  metritis  should  supervene  on  operative  treatment,  or  be 
the  result  of  septic  infection  or  gonorrhoea,  the  cervix  should  be 
dilated  (if  this  has  not  already  been  done),  the  dull  curette  used, 
and  the  uterine  cavity  gently  washed  out  with  an  antiseptic. 

Chronic  Metritis. — We  must  distinguish  between  the  condition  known  as 
*  See  the  operation  of  Curettage  and  its  dangers. 


TNFLAMMATIOS  OF  UTEUIXE  TISSUES— ACUTE  AND  CHRONTC.    331 

*  chronic  metritis '  and  the  acute  metritis  which  we  have  just  considered.  This 
state  is  rarely,  as  that  term  would  lead  us  to  suppose,  the  consequence  of 
any  acute  inflammatory  change  in  the  interstitial  tissues.  It  is  very  rarely  an 
arrested  resolution,  as  in  other  inHammatory  processes  of  a  chronic  cliaracter. 
This  remark  applies  more  especially  to  that  form  of  chronic  metritis  in  which 
the  parenchyma  of  the  uterus  is  the  part  principally  affected.  When  the  acute 
inflammation  of  the  mucous  membrane  has  subsided,  we  find  that  a  chronic 
state  of  congestion  occasionally  remains,  which  becomes  aggravated  in  time. 
The  metritic  changes  that  accompany  this  chronic  catarrhal  discharge  from 
the  endometrium  have  risen  independently  of  any  acute  inflammatory  process 
in  the  parenchyma.  It  is  this  hyperplastic  change  that  we  have  to  consider 
in  chronic  metritis.  At  the  same  time,  we  cannot,  as  Schroeder  insists, 
se})arate  from  chronic  metritis  the  idea  of  congestion,  swelling,  and  pain ; 
and  consequently  the  clinical  value  of  the  term  remains  unchanged. 

Chronic  Endometritis. 

The  division  of  endometritis  into  cervical  and  corporeal  is  of 
considerable  clinical  importance,  and  the  old  term  of  '  endocer- 
vicitis  '  still  retains  its  clinical  significance. 

Cervical  Pathology.  —  There  is  inflammation  of  the  cervical 
mucous  membrane  and  the  glands  of  Naboth,  with  hypersecretion 
of  cervical  mucus,  alkaline  in  character,  and  enlargement  and 
elevation  of  the  papillae.  These  have  the  appearance  of  granulations, 
so  that  the  cervix  assumes  a  granular  appearance.  These  granula- 
tions bleed  readily.  Such  abrasion  of  the  epithelium  is  in  error 
occasionally  spoken  of  as  '  ulceration.'  It  is  perhaps  the  most 
frequently  met  with  of  all  uterine  inflammations. 

In  that  form  of  cervical  endometritis  characterized  by  a  profuse 
secretion,  the  villosities  of  the  mucous  rugfe  are  exaggerated,  and 
sometimes  glandular  cysts-  form  projections  on  the  sui-face  of  con- 
siderable size  (Bonnet  and  Petit).  The  more  superficial  epithelial 
cells  are  elongated,  or  in  a  state  of  transformation.  The  glands  are 
more  numerous  and  scattered,  or  are  in  part  obliterated  by  the 
formation  of  cysts.  Much  more  frequently  then  in  corporeal  endo- 
metritis they  are  found  in  the  muscular  wall  in  a  flattened  condition. 
There  is  proliferation  of  the  gland-cells,  their  nuclei  being  displaced, 
the  cells  altered  in  shape,  much  elongated,  or,  on  the  contrary, 
flattened  and  shrivelled,  according  as  the  mucous  contents  are 
retained  or  not.  Around  the  glands  and  the  vessels  there  is  an 
increase  of  the  normal  cells,  and  an  infiltration  of  round  cells.  The 
hyperplasia  of  the  glands  may  give  rise  to  hypertrophy  of  the  neck, 
without  any  involvement  of  the  stroma.  Under  the  head  of  external 
cervicitis  are  included  those  inflammatory  lesions  which  are  seen  on 


332  DISEASES   OF    WOMEX. 

the  external  surface,  and  which  are  in  pathological  and  anatomical 
continuity  with  internal  cervicitis,  not  with  vaginitis.  The  intra- 
cervical  muco-purulent  flow  is  frequently  found  on  the  external 
surface  of  the  os,  or  inside  or  between  the  lips,  the  moist  patches, 
of  a  vivid  red,  being  accurately  marked  off  from  the  remainder  of 
the  vaginal  portion.  Occasionally  these  red  patches,  by  their 
undulating  folds,  recall  the  appearance  of  the  intracervical  mucous 
membrane.  They  are  the  catarrhal  surfaces  of  Hart  and  Barbour. 
At  times  they  have  an  eroded  look.  Their  surfaces  may  be  either 
smooth,  granular,  papillary,  or  villous.  With  regard  to  the  question 
of  a  true  ulceration  occurring  in  the  neighbourhood  of  the  lips  of 
the  OS,  Fischel,  Doederlein,  and  others,  ascertained  that  there  is  a 
loss  of  substance  which  exposes  the  cellular  tissue.  These  true 
ulcerations,  however,  are  very  few  in  number,  and  are  mingled  with 
pseudo-ulcerative  spots,  which,  as  well  as  the  ordinary  papillae,  are 
covered  by  cylindrical  epithelium.  They  may  be  thickened,  or 
possibly  effaced,  by  glands — -cystic  or  otherwise — which  are  analo- 
gous to  the  intracervical  glands,  and  (Cornil)  may  be  of  a  true 
sebaceous  character.  But  it  is  a  question  whether  this  partial 
pseudo-ulceration  is  not  to  be  regarded  as  an  erosion,  an  ectropion 
of  the  cervical  lips,  or  a  congenital  anomaly  (Bonnet  and  Petit). 
The  fact  that  glandular  cul-de-sacs  have  been  found  beneath  the 
pseudo-ulceration,  at  a  distance  from  the  os,  and  under  the  stratified 
pavement-lining  which  surrounds  it,  is  advanced  against  the  theory 
that  the  erosion  is  limited  to  the  superficial  layers  of  the  epithelial 
pavement  (Ruge  and  Veit,  Fischel,  Landau,  Abel,  Cornil). 

The  oblique  direction  in  which  the  glands  are  found  has  been  advanced  as 
an  argument  on  the  other  side.  Euge  and  Veit  think  that  these  are  glandular 
neo-formations ;  but  Gushing,  Bonnet,  and  Petit  question  if  they  have  not 
mistaken  the  appearance  of  incipient  epithelioma  for  them. 

The  papillary  or  granular  condition  is  found  equally  in  the  pavement  epi- 
thelium and  the  cylindrical,  which  pass  insensibly  the  one  into  the  other  in 
this  situation,  and  give  to  it  that  papillary  appearance  which  is  so  character- 
istic. Bonnet  and  Petit  view  the  theory  of  ectropion  of  the  endocervical 
mucous  membrane,  complicated  by  inflammation,  as  fitting  in  with  most  of 
the  pathological  facts.  The  ectropion  is  accompanied  by  more  or  less  ever- 
sion  of  the  subjacent  muscular  wall.  The  general  physical  appearances  of 
such  eversion  are  readily  recognized. 

Fischel  made  an  examination  of  the  uterus  of  twenty-eight  infants,  and 
found  that  in  ten  cases  the  vaginal  surface  around  the  external  orifice  was 
covered  to  a  certain  extent  with  cylindrical  epithelium,  and  not  with  the 
pavement  form,  the  usual  situation  of  the  line  of  junction  between  the  two 


INFl.AMitA  TlOX  OF  ITEIUXE  TISSrES— ACUTE  AND  CIinOMC.     3H3 


being  thus  lost.  This  constitutes  what  has  been  called  a  congenital  physio- 
logical ectropion . 

The  cylindrical  cells  may  be  interspersed  between  islets  of  flat  cells,  or 
arranged  in  clusters  analogous  to  those  of  the  intracervical  glands. 

Bonnet  and  Petit  conclude  '  that  from  the  histological  point  of  view  the 
[iseudo-ulceration  may  be  simply  an  ectropion  of  the  intra-cervical  mucous 
membrane,  attended  by  superficial  inflammation,  associated  possibly  at  the 
time  with  epithelial  and  dermal  complications  and  eversion  of  the  cervical 
lips.  It  may  be  an  erosion  of  the  pavement  lining  of  the  vaginal  surface  of 
the  uterine  neck,  which  can  be  increased  by  the  presence  of  abnormal  glands 
of  congenital  origin.'  A  congenital  anomaly  through  a  defect  in  the  trans- 
formation of  Miiller's  epithelium  'is  another  cause  of  this  condition.'  They 
tliiuk  that  true  ulceration  is  always  of  a  partial  character,  occurring  over  the 
false  form,  and  is  of  the  same  nature  as  a  follicular  erosion,  which  results 
from  the  bursting  of  Naboth's  follicles. 

Diagnosis  will  depend  more  or  less  upon  the  presence  of  the 
enlarged  follicles,  and  the  character  of  the  epithelium  which  covers 
the  abraded  part,  whether  the  ectropion  or  eversion  be  of  a 
traumatic,  inflammatory,  or  congenital  origin.  The  obliteration  of 
the  papillfe  through  swelling  of  the  mucous  membrane  accounts  for 
the  smooth  appearance  of  the  pseudo-ulcerations.  The  papillary, 
granular,  or  villous  aspect  may  be  due  to  an  incomplete  abrasion,  or 
at  certain  points  to  a  more  extensive  destruction  of  the  papillae  on 
the  vaginal  surface. 

Some  Special  Forms  of  Endometritis. — Hypertrophic  Endometritis.— With 

reference  to  corporeal  endometritis,  Bonnet  and  Petit  consider  that  hyper- 
trophic endometritis  has  in  its  nature  two  factors,  the  one  of  an  inflammatory^, 
the  other  of  a  trophic  origin.  They  divide  corporeal  endometritis  into  two 
forms  ;  (1)  that  with  hypertrophy  of  the  mucous  membrane,  (2)  that  with 
atrophy  of  the  same.  In  the  former  there  is  a  considerable  increase  of  the 
endometrium,  at  the  same  time  that  it  loses  its  normal  firmness  and  is  more 
easily  detached,  while  its  surface  is  broken  up  into  elevations  and  depressions, 
due  to  alterations  in  its  glandular  structure,  or  possibly  to  true  vegetations 
which  in  the  course  of  time  become  polypi.  The  glandular  degenerations 
or  hyperplastic  changes  are  more  manifest  and  persistent  in  some  cases,  with 
the  tendency  to  a  natural  transformation  into  the  epitheliomatous  type. 

These  glandular  changes  are  in  part  due  to  a  hypertrophy  or  hyperplasia, 
which  has  its  origin  in  the  cylindrical  epithelial  lining,  part  retaining,  and 
part  losing,  its  vibratile  cilia  (Cornil),  the  gland-tubes  being  choked  with  mucous 
and  migratUe  cells.  Hyaline  changes,  analogous  to  those  seen  in  albuminuria, 
have  been  noticed  by  Cornil.  In  the  connective  tissue  there  is  swelling  of 
the  cells  and  dilatation  of  the  vessels. 

Atrophic  Corporeal  Endometritis  includes  those  lesions  which  result  from 
interstitial  proliferation  or  the  microbal  action  on  the  normally  degenerated 
tissues.     The  interglandular  stroma  is  sclerosed ;  the  coiporeal  glands  are 


334 


DISEASES   OF    WOMEN. 


atrophied ;   the  lining  epithelium  is  transfornaed  or  disappears ;   ulcerations 
occur  discharging  pus  or  blood. 

Hyperplastic   Endometritis. — Here   proliferation    and   hj'pertrophj'   of  the 

connective   tissue  are   the 


'  .',;•' :^^/'^.-'-': ■■.z~-  ■•^f'u^:-   -j. 


principal  features,  the  cells 

not  only  swelling  and  pro- 

iferating,  but  assuming  the 

aspect    of    true     decidual 

cells,    fusiform     or    giant. 

Sinety  has  described  a  form 

of  interstitial  endometritis 

hich  he  discovered  em- 

onic  vegetations. 

Hsemorrliagic  Endometri- 


mucous  membrane.  That 
condition  to  which  we  have 
already  referred,  in  which 
polypi,  whether  glandular, 
muco-fibroid,  or  vascular, 
are'jfound,  has  been  denomi- 
nated '  polypoid.'  In  these  cases,  there  is  a  considerable  increase  in  the 
interstitial  tissue. 

Shaw-Mackenzie  emphasizes  the  difficulties  of  diagnosis  in  cases  of  hsemor- 

rhasric  endometritis,  and  the 
ff 


Fig.  239. — ADExo-CAECiyoiiA  of  Cervix  Uteri. 
(X  100.) 


i^i''.';S^'^y-'{-^<l.<^i^  'ii''V-C'^; 


4i>im 


dififerentiation  between  it 
and  malignant  disease  as 
sarcoma  and  adeno-sarcoma. 
In  some  cases  enlargement 
and  irregularity  of  the  ute- 
rine glands,  with  infiltration 
of  their  walls  with  nucleated 
round  cells,  which  also  are 
between  the  glands, 
rise  to  extensive  pro- 
liferation. Large  and  nume- 
vessels  with  hemor- 
rhages were  visible  in  the 
cellular  matrix,  rendering 
the  appearances  similar  to 
those  seen  in  the  columnar 
cancer.)  The  small  celled  in- 
filtration makes  the  diagnosis 
from  sarcoma  difficult,  and 
the  differentiation  of  epithe- 
lial or  sarcomatous  cells  from  inflammatory,  when  the  latter  are  isolated,  noteasy. 


Fig.  240. — Papillary  Eeosiox  of  the  Cervix, 
(Taegett.) 


PLATE   XVTIT. 


,-;;«, 


J^ 


i&i>?5t^-;. 


U 


^ 


*1m*- 


■■■•-■4i.?i 


ife*-. 


CrRETTIXGS   FROM   A   CaSE   OF   GLAXDrLAE    ExDOilETKITIS.      (AuTHOK.) 

Cystic  degeneration  in  a  case  of  h£emorrhagic  endometritis.  The  tubules  were  distended  into 
small  cysts.  There  was  also  much,  round-celled  infiltration  of  the  stroma.  [For  sequel  to 
this  case,  see  plate  over  page.] 

PLATE    XIX. 


POETIOX     OF     CURETTINGS     TAKEN    FROM     A     CaSE     OF    EXDOMETRITIS    'WITH 
FOLLICELAR   DeGEXERATIOX   OF   THE    CeETIS;  AXD   ErOSIOX.      (AeTHOR.) 

There  is  desquamation  of  the  gland  epithelium,  with  cedema  of  the 

subjacent  muscle.  [^Tofacep.  334. 


INFLAMMATION  OF  UTERINE  TISSUES— ACUTE  AND  CIIIiONIC.    335 


Fig.  2-il. — H^emorrhagic  Exdometritis.    (High  power.)    (Shaw  Mackexzu;.) 

A,  swollen  gland;  B,  inflammatory  cell  proliferation  of  matrix  and  blurred 
vessels  in  field.  A  section  of  curettings  in  hsemorrhagic  etdometritis,  in 
which  the  ultimate  ending  of  the  case  showed  that  it  was  sarcoma ;  the 
structure  of  the  interstitial  tissue  presented  a  marked  deviation  from  the 
normal,  approaching  adeno-sarcoma. 


^' 


Fig.  242. — 'Catarrhal'  Endometritis.     (Shaw  3Iackenzie.) 
The  glands  are  somewhat  enlarged  and  the  cell  proliferation  is  not  marked. 


336  DISEASES   OF    WOMEX. 

In  some  instances  there  is  simply  hyperplasia  of  the  glandular  layer  of  the 
mucosa  without  invasion  of  the  uterine  wall.     These  conditions  would  appear 

to  be  transitional  between 
benign  and  mahgnant,  the 
passage  of  a  benign  adenoma 
into  an  adeno-caixinoma.  In 
those  cases  in  which  the 
proliferating  masses  project 
into  the  uterine  cavity,  there 
is  an  epithelial  proliferating 
columnar  arrangement ;  here 
microscopic  examination  en- 
ables us  more  readily  to  dis- 
tinguish the  benign  from  the 
malignant. 

In  the  case  of  erosions  of 

the  cervix  and  os  care  has 

to  be  taken  in  the  differential 

diagnosis  from  the  mahgnant 

states.      Syphilitic  erosions 

Fig.  248.— Ekdumktkitis  Hyperplastica.         which  bleed  readily  and  are 

(Author.)  associated  with  an  impaired 

state  of  health  are  apt  to  be  confounded  with  malignant  conditions. 

Treatment  of  Haemorrhagic  Endometritis  by  Curettage  and  Chromic  Acid. — 
The  conditions  which  the  term  '  haemorrhagic  endometritis '  involves  are 
various.  Operating  on  a  case  of  this  nature,  after  dilatation,  I  found  a  small 
raspberry-like  mass  in  the  uterus.  The  pathological  report  pronounced  it  to 
be  of  a  decidedly  malignant  nature.  This  was  many  years  since,  yet  the 
patient  is  at  the  pi^esent  day  alive  and  well. 

In  previous  editions  of  this  work  cases  have  been  recorded  in  which  there 
had  been  for  years  continuous  heemorrhage  with  occasional  excessive  menor- 
rhagia,  completely  cured  by  thorough  curettage  and  the  application  of 
chromic  acid  (one  drachm  to  the  ounce  solution)  with  the  administration  of 
hydrastis  and  stypticin.  In  these  cases  the  general  pathological  state  was 
infiltration  of  the  stroma  of  the  endometrium  with  inflammatory  products, 
increase  in  number  of  glandular  tubules,  which  were  hypertrophied  and 
dilated,  and  more  or  less  abundance  of  the  cellular  stroma. 


Vapo-Cauterization  of  the  Uterus. 

Though  in  the  last  edition  of  this  work,  this  method  of  Snegiretf 
(1886)  and  Pincus  (1899)  was  described,  and  the  appliance  of  Pincus 
was  figured,  I  have  not  resorted  to  it,  being  quite  satisfied  with  the 
other  methods  of  treatment  advocated,  I  then  said  :- — '  So  far  it 
does  not  appear  that  this  treatment  has  any  advocates  in  this 
country.' 


Fig.  '243a. — Fixers'  Improved  Apparatus  for  Atmocacsis  axd  Zestocadsis. 

Showing  lamp  and  boiler,  with  thermometer  ;  also  wooden  specula,  with  the  steam- 
conducting  tube,  the  atmocautery  and  various  intra-uterine  catheters,  some 
having  apertures  at  the  end,  some  laterally,  and  others  with  spiral  openings. 


Fig.  243b. — Uterus  and  Adnexa  removed  by  Atjiocausis.    (Pixcus.) 

[To  face  p.  338. 


SSh 


PLATE   XlXa.— Sequel  of  Glandular  Endometritis.       See  Plate  XVIII.) 

The  patient,  from  whom  this  uterus  and  adnexa  were  removed,  was  aged  49, 
height  6  feet  1  inch.  She  had  been  twice  curetted,  and  the  uterine  canal 
wiped  out  with  chromic  acid  solution.  Before  each  curettage  she  was 
blanched  from  hsemorrhage,  and  had  a  cardiac  hicmic  murmur,  with  feeble 
second  sound.  Each  oi^eration  gave  temporary  relief.  The  bleeding  recur- 
ring, I  removed  the  uterus  and  adnexa  by  supra-vaginal  hysterectomy. 
The  examination  of  the  specimen  by  Dr.  Lockyer  showed  a  thickened 
endometrium,  covered  by  pultaceous  deposit,  consisting  of  epithelial  deT^ris. 
(When  the  uterus  was  divided  after  removal,  a  quantity  of  this  pultaceous 
ma.terial,  closely  resembling  muco-pus,  exuded  from  the  left  cornu.)  The 
excessive  desquamation  of  the  glands  and  the  accumulation  of  epithelium 
explained  the  collection  in  the  left  cornu  of  this  thick  debris,  not  unlike 
pus.  There  was  a  small  circular  fibroid  in  the  anterior  wall.  The  tubes 
were  slightly  swollen  and  the  flmbrise  oedematous.  The  left  ovary  contained 
two  small  blood  cysts.  The  right  had  a  thin-walled  cyst  at  its  inner  pole. 
The  patient  is  now  in  good  health. 


INFLAMMATION  OF  UTEMINE  TISSUES— ACUTE  AND  ClIIiONlC.    3;57 


This  may  have  been  due  to  unfavourable  reports  of  the  treatment. 
Necrosis  of  the  uterus  occurred  in  a  case  of  Van  de  Velde's,  where  every 
care  had  been  talcen  with  the  application  of  the  vapo-cauterization ;  yet  per- 
foration and  septic  peritonitis  followed.  The  temperature  of  tlie  steam  in 
this  particular  case  was  105°  C. 

Since  then  (1901),  however,  the  method  has  found  favour  with 
several  eminent  gynaecologists  in  the  United  Kingdom,  and  has 
been  practised  with  success  both  in  this  country  and  in  America. 
So  reliable  an  authority  as  Fritsch  has  pronounced  it  to  be  '  safe, 
painless,  and  eflective,'  and  others  of  large  experience  also  assert 
that  it  is  quite  painless.  I  do  not  apologize  for  quoting  the  clear 
description  of  the  modus  operandi  given  in  a  review  of  Pincus'  work,* 
in  which  the  advantages  and  risks  of  the  method  are  fully  entered 
into  by  the  author. f 


Fig.  244.— a.  Combination  of  Bell-shaped  Forceps  with  Movable 
Handles.     B.  Tenaculum  with  same.J 

'  The  improved  apparatus  consists  of  a  boiler  of  6-litre  capacity,  and 
capable  of  resisting  a  pressure  of  over  21  atmospheres,  in  which  the  steam  is 
generated,  and  in  the  top  of  which  a  thermometer  and  a  safety  valve  are 
lifted.  From  the  upper  part  of  the  boiler  a  curved  tube  projects,  to  which  is 
joined  an  indiarubber  tube  1  metre  in  length.  To  the  end  of  this  is  attached 
the  intrauterine  catheter  itself,  made  very  much  on  the  plan  of  the  ordiaary 
Bozemann's  catheter,  but  having  a  non-conducting  cover  fitted  over  that 
portion  which  lies  in  the  cervix,  and  a  tube  fitted  to  the  return  opening  to 
carry  oft' the  waste  steam.  To  the  instrument  is  attached  a  wooden  handle, 
and  just  above  this  there  is  a  two-way  cock  to  regulate  the  supply  of  steam 
to  the  uterus,  the  upper  part  of  the  tap  being  of  wood,  so  that  the  operator 
may  not  burn  his  fingers  when  using  it.  If  we  intend  using  a  temperature 
from  100°  to  105°  we  fill  the  boiler  one-third  full,  and  if  from  105°  to  115° 
one-half  full.     The   indiarubber  tube  is  specially  constructed  to  resist  the 

*  Brit.  Gyn.  Jour.,  vol.  sxiv.,  Aug.,  190;^. 

t  Since  writing  the  above,  I  have  been  favoured  by  Dr.  Pincus  with  a  gift  of 
his  work  and  cliches — '  Atmokausis  and  Zestokausis — Die  Behandlung  mit  Hoch- 
gespanntem  Wasserdampf  in  der  Gynjekologie,'  etc.,  by  Dr.  Ludwig  Pincus, 
Frauenarzt,  in  Danzig,  Wiesbaden.     Verlag  von  T.  F.  Bergmann,  1903. 

X  See  p.  338. 

z 


338  DISEASES   OF    WOMEN. 


pressure  of  the  superheated  steam,  and  is  further  strengthened  by  a  covering 
of  close  webbing.  It  should  not  exceed  a  metre  in  length  for  private  practice, 
though  in  a  clinique  it  is  often  well  for  purposes  of  demonstration  to  have  it 
as  long  as  two  metres.  The  non-conducting  material  used  to  cover  the 
cervical  portion  of  the  catheter  is  made  of  a  fibre  which,  manufactured  in 
America  by  some  patent  process  of  subjecting  wood  shavings  to  hydraulic 
pressure,  is  now  extensively  used  to  insulate  the  various  parts  of  electrical 
machines.  It  can  be  cut  and  turned  like  wood,  and  withstands  the  action  of 
boiling  water  (no  soda)  and  of  acids  very  well,  and  so  can  be  thoroughly  dis- 
infected. For  cases  in  which  contact  burning  would  be  specially  dangerous, 
such  as  interstitial  myomata,  the  intrauterine  portion  of  the  catheter  is  made 
entirely  of  fibre ;  in  others,  on  the  contrary,  where  contact  burning  is 
intended,  the  uterine  piece  of  the  catheter  is  made  entirely  of  metal,  and  is 
not  provided  with  holes,  so  that  it  acts  like  the  ordinary  thermo-cautery,  but 
in  a  milder  way.  There  is  also  another  form  of  metal  tap  provided,  which  is 
larger  and  flatter,  and  is  used  for  stopping  hajmorrhage  in  operations  on 
parenchymatous  organs. 

'Besides  these  essential  instruments  there  are  some  which  are  of  great  use 
if  the  operator  be  without  skilled  assistance,  viz.  a  set  of  short  wooden  specula, 
to  prevent  the  vagina  being  scalded  should  the  steam  escape  by  accident 
from  the  cervix  during  the  operation,  and  a  pair  of  ordinary  bullet  forceps, 
with  removable  handles.  These  latter  enable  us  first  to  fix  the  cervix  with 
the  forceps,  and  after  having  removed  the  handles,  to  pass  the  speculum  pver 
the  blades  and  then  to  replace  the  handles.  We  can  in  this  way,  even  when 
it  is  considerably  displaced,  draw  the  cervix  into  the  speculum. 

'  Preparations  for  the  Operation. — The  patient  is  placed  on  her  back,  the 
cervix  is  seized  near  the  commissure  with  a  pair  of  the  special  atmocausis 
forceps,  one  of  the  short  wooden  specula  is  passed  over  the  forceps,  -and  the 
handles  of  the  latter,  which  have  been  removed  to  pass  the  speculum,  are 
replaced.  In  all  cases  of  preclimaeteric  haemorrhage,  where  there  is  the 
least  suspicion  of  malignant  disease,  this  must  first  be  excluded,  either  by 
palpation  of  the  interior  of  the  uterus,  or  by  microscopic  examination  of  the 
mucous  membrane,  or  by  both.  When  using  the  curette  for  this  purpose 
special  attention  should  be  paid  to  the  fundus  and  cornua,  and,  when  possible, 
the  atmocausis  should  not  follow  immediately  on  the  curetting.  The  dilata- 
tion of  the  cervix,  so  as  to  allow  the  catheter  with  its  protective  covering  of 
fibre  to  be  readily  introduced,  is  the  first  step  in  the  operation,  and  if  the 
cervix  be  rigid,  and  the  symptoms  not  pressing,  is  best  effected  by  laminaria 
tents,  more  especially  if  we  intend  to  explore  the  cavity  with  the  finger,  a 
step  which  may  in  the  end  save  time,  as  it  may  render  curetting  unnecessary. 
Before  any  attempt  is  made  to  introduce  the  catheter,  all  mucus,  blood 
clots,  or  placental  remains,  must  be  carefully  removed  from  the  interior  of  the 
uterus.  This  is  probably  best  effected  by  washing  out  the  uterus  with  a 
1  per  cent,  solution  of  peroxide  of  hydrogen.  The  length  of  the  uterus  and  of 
the  cervix  should  be  carefully  ascertained  before  the  dilatation  takes  place, 
and  the  condition  of  the  walls  of  the  uterus,  and  the  absence  of  any  complica- 
tion in  the  adnexa  and  parametria,  determined.  In  the  large  majority  of 
cases  narcosis  is  unnecessary.     If  there  be  any  doubt  as  to  the  condition  of 


INFLAMMATJOS  Oh'  UTEliJI^E  TISSUES— ACUTE  AND  CHRONIC.    :i39 

the  adnexa,  the  patient  must  be  carefully  watclied  during  previous  menstrua- 
tion to  find  out  if  there  be  any  evening  rise  of  temperature  or  swelhiig  of  tlie 
tubes.  If  there  be  any  exacerbation  during  menstruation,  or  after  the  syste- 
matic appHcatiou  of  intrapclvic  pressure  (IJelastuiigstherapie)  the  case  is 
unsuited  for  atmocausis  or  zestocausis. 

'The  Operation. — The  boiler  is  tilled  with  about  7  ozs.  of  water  for  tempe- 
ratures of  100°  to  105°,  and  11  ozs.  of  water  for  temperatures  of  105°  to  115°. 
If  there  be  hajraorrhage  it  is  well  to  use  a  tliree  per  cent,  solution  of  formalin 
instead  of  plain  water.  For  ordinary  cases  the  revolver  burner  is  the  best, 
but  for  tlie  lower  temperatures,  or  if  there  be  any  delay  in  the  operation, 
the  double  burner  is  used,  of  which  only  one  side  need  be  lighted.  If  the 
two-way  cock  be  placed  obli<[uely  no  steam  can  escape  from  the  boiler,  and 
consequently  the  temperature  rises  quickly,  and  the  rate  at  which  this  takes 
place  can  be  regulated  by  the  amount  of  steam  that  is  allowed  to  escape  and 
the  sort  of  burner  that  is  used.  The  apparatus  itself  should  not  be  carried 
about,  but  should  be  placed  on  a  table  or  on  a  specially  constructed  stand. 
As  soon  as  everything  is  ready  the  two-way  cock  is  placed  transversely,  and 
any  condensed  water  that  has  collected  in  the  indiarubber  tube  is  expelled. 
The  point  of  the  catheter  is  now  depressed,  and  the  cock  turned  through  a 
quarter  of  a  circle ;  the  steam  then  escapes  through  the  catheter,  warming  the 
whole  apparatus,  and  clearing  out  any  still  remaining  water.  The  cock  is 
now  turned  back  till  it  is  nearly  transverse,  and,  the  handle  of  the  instrument 
being  a  little  depressed,  the  catheter  is  quickly  introduced  into  the  uterus. 
As  soon  as  it  is  well  in,  the  cock  is  slowly  turned  so  as  to  point  along  the 
tube  of  the  catheter,  and  the  steam  is  thus  gradually  admitted  into  the 
uterus.  We  do  not,  however,  count  the  seconds  till  the  steam  begins  to 
escape  from  the  waste  steam  tube.  The  catheter  should  not  be  allowed 
to  remain  in  one  position  in  the  uterus,  but  should  be  moved  a  little  from 
side  to  side,  so  as  to  avoid  the  risk  of  contact  necrosis.  The  fibre  cervix 
protector  must  never  be  drawn  out  so  far  as  to  leave  the  inner  os  unprotected. 
The  operation  should  be  shortened  in  proportion  to  the  readiness  the  uterus 
shows  to  contract,  the  amount  of  contraction  of  the  uterus  being  determined 
by  the  hand  placed  on  the  fundus.  Before  removing  the  catheter  from  the 
uterus  the  steam  must  be  shut  off  by  turning  the  stop-cock  either  obliquely 
or  transversely.  The  catheter  should  at  once  be  removed  should  the  return 
tube  become  stopped,  except  in  cases  of  bad  hsemorrhage,  for  then  the  stop- 
page of  the  tube  causes  the  tension  and  heat  of  the  steam  to  rise,  and  thus 
increases  its  hemostatic  action.  In  other  cases  the  tube  should  be  cleared 
out  thoroughly,  the  uterus  washed  out  with  a  1  per  cent,  solution  of  peroxide 
of  hydrogen,  and  the  catheter  again  introduced.  In  estimating  the  time 
during  which  the  steam  should  be  allowed  to  work,  we  must  take  into  con- 
sideration the  size  of  the  uterine  cavity,  the  thickness  of  its  walls,  and,  above 
all,  the  contractility  of  its  muscular  fibre,  the  rule  being  to  use  the  highest 
possible  temperature  for  the  shortest  possible  time.  If  necessary  the  opera- 
tion may  be  performed  in  the  out-department,  but  is,  of  course,  safer  if  done 
in  hospital,  and  when  the  patient  is  in  bed.' 

In  discussing  the  necessity  for  narcosis  and  assistance,  whether 


340  DISEASES   OF   WOMEN. 


the  operation  should  be  undertaken  by  the  general  practitioner,  if 
ambulant  treatment  be  safe,  and  the  relative  positions  of  atmocausis 
and  zestocausis  to  the  operation  of  curettage,  Pincus  arrives  at 
these  conclusions.  He  does  not  advocate  anaesthesia  save  in  ex- 
ceptional cases,  appearing  to  regard  the  sensibility  of  the  woman  to 
pain  as  a  safeguard,  she  being  thus  able  to  give  the  alarm  should 
there  be  any  misapplication  in  the  use  of  the  instrument.  He 
advises  that,  as  a  rule,  the  application  should  be  performed  in  bed, 
where  the  patient  can  remain  for  some  days,  and  not  in  the  out- 
patient department.  It  is,  he  considers,  also  well  to  have  assistance, 
though  it  may  be  dispensed  with.     He  thus  proceeds  when  alone — 

'  The  stand  is  placed  within  easy  reach  of  the  right  hand  of  the  operator,  and 
the  thermometer  tm'ned  so  that  the  index  can  be  read  off.  He  first  takes  the 
atmocauterj  in  the  right  hand  and  with  the  left  hand  opens  the  two-way 
cock,  which  he  shuts  again  as  soon  as  the  condensed  water  has  all  escaped. 
The  left  hand  then  grasps  the  forceps,  and  the  right  hand  introduces  the 
caiitery.  The  left  hand  now  leaves  the  forceps  and  turns  on  the  steam;  it  is 
then  placed  over  the  fundus  to  control  it,  and  may  pass  a  couple  of  times 
from  the  fundus  to  the  forceps  and  back  again,  as  found  necessary.  Finally, 
the  left  hand  turns  off  the  steam,  again  grasps  the  forceps,  and  then  the  right 
hand  removes  the  atmocauterj'.' 

Pincus  (we  think  wisely)  does  not  approve  of  the  operation  being 
performed  by  the  general  practitioner,  involving  as  it  does  a  most 
accurate  diagnosis,  and  very  special  experience  in  gynaecological 
methods.  He  considers  atmocausis  a  preferable  method  of  treatment 
to  curettage,  though  the  latter  step  at  the  climacteric  period  should 
precede  the  former,  an  interval  of  ten  to  twenty  days  elapsing 
between  the  curettage  and  the  treatment  by  steam.  Only  rarely 
during  the  childbearing  period  should  the  two  operations  be  combined. 

The  indications  for  atmocausis  or  zestocausis  may  be  absolute  or  relative. 

T.  Atmocausis  is  absolutely  indicated  : — 

{a)  In  all  cases  of  uterine  hsemon-hage  which  we  fail  to  influence  or  cure 
by  the  usual  methods. 

To  these  belong  :  (1)  Certain  form  of  preclimacteric  haemorrhage ;  (2)  all 
cases  of  hajmophilia  ;  (.3)  certain  cases  of  bleeding  myomata,  and  of  hsemor- 
rhage  from  inoperable  cancer  corporis  uteri ;  (4)  certain  forms  of  endome- 
tritis hsemorrhagica  (endometritis  hyperplastica,  Olshausen)  ;  (5)  atonic  and 
endometritic  hfemorrhage,  especiallj'  after  abortion  or  late  in  the  puerperium. 

(&)  To  produce  sterilitj'^  in  women  with  incurable  diseases. 

II.  Atmocausis  may  be  relatively  indicated  : — 

(a)  In  subinvolution,  which  does  not  yield  to  treatment. 

(b)  In  inflammatory  affections  where  the  -curette  is  indicated  we  may  use 
the  atmocautery  instead  of  it,  or  as  complementary  to  it. 


ISFLAMMATIOX  OF  UTERINE  TISSUES— ACUTE  AND  CHRONIC.    341 


(c)  In  a  special  class  by  themselves  we  place  :  (1)  Endometritis  tuberosa  : 
(2)  endometritis  gonorrhceica ;  (3)  endometritis  saprica  ;  (4)  endometritis 
puerperalis  septica  incipiens. 

III.  Zestocausis  is  absolutely  indicated  : — 

(a)  When  we  want  to  cauterize  certain  circumscribed  portions  of  the 
endometrium  (cornua). 

(b)  In  certain  cases  of  endometritis  dysmenorrhoeica. 

IV.  It  is  relatively  indicated : — 

(a)  When  in  a  small  niilliparous  uterus  the  curette  is  indicated  for  in- 
flammation, we  may  use  the  zestocausis  either  instead  of  it.  or  in  combination 
with  it. 

(b)  In  cases  of  obstinate  endocervicitis  and  obstinate  erosion,  as  being  a 
milder  application  than  the  thermocautery. 

(c)  In  the  treatment  of  obstinate  fistula,  and  in  operations  on  the  liver, 
spleen,  etc. 

Contra-indications.— These  are  the  same  for  atmocausis  and  zestocausis  as 
for  all  other  methods  of  intrauterine  treatment. 

The  contra-indication  is  absolute  : — 

(a)  If  malignant  disease  be  present. 

(&)  If  there  be  any  infiammatory  or  painful  complications  in  the  adnexa; 
or  the  parametria,  especially  tumours  in  the  tubes. 

(c)  When  there  is  any  exacerbation  of  the  symptoms  during  menstruation 
or  after  treatment  by  intrapelvic  pressure  ('  Belastungstherapie  ')• 

{d)  If  the  patient  complain  of  acute  pain  during  the  application  of  the 
steam  the  operation  must  be  at  once  abandoned. 

Zestocausis  is  contra-indicated  in  all  cases  where  the  uterine  walls  are  thin 
and  relaxed. 

It  appears  obvious,  even  from  the  description  of  the  method  and 
the  precautions  insisted  upon  by  Pincus  himself,  that  this  operation 
is  not  one  to  be  lightly  undertaken.  'The  success  of  atmocausis 
depends,'  he  says,  '  on  the  proper  selection  of  the  cases  and  upon 
proper  handhng  of  the  apparatus.'  At  the  same  time  he  does  not 
consider  it  either  a  substitute  or  a  complement  for  curettage,  which, 
if  efficient,  he  regards  as  more  severe  than  either  atmocausis  or 
zestocausis,  which,  if  properly  applied,  is  also  more  decidedly 
curative.*  Nor  does  my  experience  accord  with  his  views  on  curet- 
tage, which  if  thoroughly  carried  out,  with  proper  aseptic  precautions, 
yields  most  satisfactory  results,  and  is  decidedly  curative  in  the 
great  majority  of  cases.  In  obstinate  hemorrhagic  endometritis,  in 
adenomatous  states  of  the  endometrium,  in  endometritis  hyper- 
plastica  and  in  fungous  and  septic  endometritis,  where  curettage 
fails  zestocausis  may  eflect  a  cure  and  save  the  uterus  from  ablation. 

*  Mmwts.  f.  Geh.  u.  Gyn.,  bd.  xvi..  s.  74.5:  Brit.  Gyn.  Jour..  Feb..  190o. 


342  DISEASES   OF    WOMEN. 


It  must  ever  be  contra-indicated  in  a  thin-walled  uterus,  and  where 
there  are  adnexal  complications. 

Endometrectomy. 

Casati  originated,  and  Diihrssen  adopted,  this  method  for  the  treatment  of 
recurrent  hsemorrhagic  endometritis  where  curettage  had  failed.  The  anterior 
vaginal  vault  is  opened,  and,  the  anterior  wall  of  the  cervix  having  heen 
exposed,  the  peritoneum  is  either  detached  from  it  or  divided.  The  uterus 
is  next  incised  as  far  as  the  fundus,  and  the  uterine  and  cervical  mucosa  are 
stripped  off.  The  incision  may  be  of  a  T  shape.  It  is  closed  by  circular 
sutures  earned  round  the  uterine  cavity  below  the  incised  surface.* 

Chronic  Endometritis— Causation  (Predisposing  and  Exciting). — 
We  may  group  the  causes  of  chronic  endometritis  thus  : — 

1.  Predisposing — 

Constitutional  (tubercle,  syphilis,  chlorosis). 

Defective  diet. 

Excessive  lactation. 

Frequent  labours  and  subinvolution. 

Mental  causes. 

2.  Exciting — 

Excessive  coition. 

Exposure  to  cold  during  menstruation. 

Gonorrhoea. 

Vaginitis. 

Displacements. 

Stenosis  of  cervix. 

Polypi. 

Laceration  of  cervix. 

Abortion,  miscarriage,  parturition. 

Symptoms  and  Physical  Signs.— the  chief  are  pelvic  pains  and 
backache,  attended  by  difficulty  in  walking  ;  leucorrhoea  of  a  viscid 
character;  occasionally  vaginitis;  dysmenorrhcea ;  djspareunia ; 
sterility,  from  the  impediment  to  the  passage  of  the  semen,  and  the 
action  of  the  secretion  on  the  spermatozoa;  deterioration  in  the 
general  health. 

On  examination  by  the  finger  and  speculum,  we  often  find  the 

lips  of  the  OS  uteri  swollen,  or  denuded  of  its  epithelium,  and  some 

surroundiiig  erosion  or  granular  degeneration  of  the  adjacent. cervix. 

Occasionally  there  is  the  characteristic  viscid  discharge   blocking 

*   Centralh.  f.  Gyn.,  s.  1353,  1898. 


IXFLAMMATIOS  OF  UTERINE  TISSUES— ACUTE  AND  CHROXIC.    34H 


up   the   cervix,  which   is   removed   with   difficulty.     A  version  or 
flexion  may  be  detected. 

Prognosis. — As  it  is  the  most  frequent,  so  is  it  often  the  most 
inveterate  of  uterine  morbid  states.  Even  if  we  succeed  in  altering 
the  nature  of  the  secretion,  and  finally  arrest  it,  a  lull  in  the  treat- 
ment is  occasionally  followed  by  a  return  of  the  old  complaint  in  as 
aggravated  a  form  as  before.  The  longer  the  aflfection  has  lasted, 
and  the  more  copious  and  viscid  the  discharge,  especially  in  those 
cases  in  which  the  uterus  is  malformed  or  displaced,  the  worse  is 
the  prognosis. 

Treatment  (Local  Therapeutic  Measures ). — The  methods  of 
applying  various  substances  to  the  interior  of  the  uterus,  and  the 
manner  of  dressing  the  cervix  have  been  referred  to.  The  first  and 
most  important  point  to  decide  is,  whether  the  inflammation  be 
localized  in  the  cervix,  or  involve  the  fundus.  In  this  we  must  be 
guided  by  the  character  of  the  discharge,  and  the  size  and  sensitive- 
ness of  the  body  of  the  uterus.  "We  must  also  in  all  cases  make  a 
careful  bi-manual  examination  of  the  adnexa,  and  satisfy  ourselves 
as  to  their  condition.  If  there  be  adnexal  disease  this  will  neces- 
sarily influence  our  decision  as  to  the  line  of  treatment  we  should 
adopt. 

Assuming  that  the  cervix  alone  is  inflamed  in  a  case  in  which  the 
cervical  canal  is  narrow  and  where  there  is  stenosis  of  the  isthmus, 
our  first  step  should  be  to  secure  such  dilatation  of  the  cervical  canal 
as  will  permit  of  the  free  flow  of  any  discharge,  and  allow  room  for 
a  topical  application  to  the  mucous  membrane.  This  is  best  done 
by  division  and  dilatation  of  the  cer^TX  in  the  manner  already 
described.  The  loss  of  blood  consequent  upon  the  incisions  will  be 
of  service. 

The  hot  vaginal  douche  may  be  used  either  with  borax,  carbonate 
of  soda,  boiled  starch,  Condy's  fluid,  laudanum,  tincture  of  iodine, 
or  liquid  extract  of  hydrastis  added  to  the  water.  Kreuznach  m  Utter 
lauge  or  that  of  Woodhall  is  an  excellent  addition  (two  ounces 
to  the  quart).  Depletion  of  the  cervix  repeated  a  few  times  hastens 
the  cure.  Such  applications  as  carbolic  acid  and  glycerine,  ichthyol 
and  glycerine,  formic-aldehyd  10  to  20  per  cent.,  extract  of 
hydrastis  and  glycerine,  liniment  or  tincture  of  iodine  and  glycerine, 
chromic  acid  solution,  nitrate  of  silver,  Braxton  Hicks'  fused  zinc 
crayons,  or  those  of  iodoform,  are  useful.  The  nitrate  of  silver  may 
be  applied  on  a  uterine  probe,  by  first  fusing  a  little  of  the  silver  salt 
in  a  small  crucible  (Fig.  124)  over  a  spirit-lamp,  and  then  dipping 


344 


DISEASES   OF   WOMEN. 


the  point  of  the  probe  into  the  cup,  so  as  to  get  a  film  of  the  nitrate 
of  silver  on  it.  But  by  far  the  most  efficient  and  perfectly  safe 
agent,  when  applied  with  due  care,  is  fuming  nitric  acid.  (See  page 
142  for  full  directions  for  its  application.)  After  making  use  of  any 
of  these  agents,  a  glycerine  tampon  should  be  passed  into  the  vagina. 

Menge  first  advocated  the  application  of  formalin  on  hard  rubber  rods,  in 
strengths  varying  from  20  to  50  per  cent.  I  have  used  these  rods  for  some 
time,  and  find  that  they  are  not  acted  upon  by  the  solution.  (Schaedel, 
Leipzig.)     Smyly  also  speaks  highly  of  formalin.     Ichthyol  solution,  10  to 


Fig.  245.— Dressing  the  Cervix  with   Sims'  Speculum  and  Uterine  Probe 
IN  THE  Lateral  Position. 

20  per  cent.,  is  another  efficient  application  in  chronic  inflammatory  states  oi 
the  cervical  endometrium.  It  may  also  be  administered  with  benefit  inter- 
nally. Like  many  other  vaunted  remedies,  it  fails  in  some  cases  to  give  any 
result.  In  the  majority  of  cases  of  cervical  endometritis,  the  most  rapid  cure 
follows  curettage  of  the  aifected  canal,  and  the  application  of  chromic  acid. 

General  Treatment. — The  patient  must  abstain  from  coitus ;  have 
as  much  outdoor  exercise  as  is  suitable  to  her  strength;  much 
standing  is  to  be  avoided.  Change  of  air,  proper  tepid  bathing 
of  the  body,  simple,  yet  nutritious,  diet,  moderation  in  alcohol,  long 


TNFLAMyfATIOX  OF  UTERTXE  JISSUES— ACUTE  AXD  CHROMIC:    345 


hours  of  rest,  careful  attention  to  the  secretions,  are  all  important 
aids  towards  curing  the  disease.  The  most  valuable  medicines  are 
arsenic,  quiiune,  hydrastis,  ichthyol,  viburnum  pruiiifoliuni,  the 
mineral  acids  \vith  the  vegetable  tonics,  bark,  calumba,  gentian, 
nux  vomica.  If  there  be  nervous  excitement  and  much  pain,  heroin 
and  the  bromides  are  indicated. 

Chronic  Corporeal  Endometritis. 

"NMiile  it  is  of  the  utmost  importance  to  recognize  the  clinical  fact 
that  chronic  cervical  endometritis  per  se  is  a  frequently  occurring 
affection  of  the  uterus,  it  must  not  be  thought  that  endometritis  of 
the  body  is  ordinarily  met  with  apart  from  the  cervical  catarrh.  On 
the  contrary,  the  corporeal  inflammation  is  generally  attewJed  hy  varying 
degrees  of  cervical  endometritis.  In  chronic  corporeal  endometritis, 
not  only  are  the  utricular  glands  of  the  body  involved,  but  also  those 
of  Naboth  in  the  cervix.  The  exaggeration  of  the  natural  secretion 
from  the  utricular  glands  is  the  most  prominent  sign  of  the  affection. 
Post-mortem  examinations  show  that  the  mucous  membrane  is  found, 
at  the  commencement  of  this  disorder,  swollen  and  reddened ;  later 
on  it  is  paler  and  of  a  gray  colour.  Finally,  the  glands  are  atrophied, 
the  mucous  membrane  is  deprived  of  epithelium,  and  the  deeper 
layers  form  sprouting  granulations,  which  at  times  assume  the 
appearance  of  small  polypi. 

The  cavity  of  the  body  is  enlarged  when  the  disease  lasts  for  any 
length  of  time,  and  there  may  be  a  mere  lining  of  connective  tissue, 
which  takes  the  place  of  the  natural  mucous  membrane. 

Causation. — AH  those  causes  which  operate  in  producing  the 
cervical,  likewise  bring  about  the  corporeal  endometritis.  There 
are  a  few  uterine  affections  with  which  the  latter  condition  is 
constantly  associated,  or  that  it  is  a  sequence  of — ■ 

Subinvolution  of  the  uterus. 

Abortion  and  miscarriage. 

Obstructive  dysmenorrhcea. 

Displacement. 

Gonorrhoea. 

Vaginitis. 

It  may  also  follow  prolonged  lactation. 

Symptoms   and   Physical    Signs. — The    principal   are   a    glairy 
discharge,  at  times   coloured,  and  tinged  with   blood,   or  purulent 


346  DISEASES   OF   WOMEN. 

and  shreddy  ;  amenorrhcea,  dysmenorrhoea,  or  metrorrhagia  ;  all  the 
symptoms  already  noted  of  cervical  endometritis  in  an  aggravated 
form.  Frequently  there  is  enlargement  of  the  uterine  canal,  and 
increased  sensitiveness  of  the  entire  uterus,  which  by  bimanual 
examination  is  found  enlarged. 

Treatment. — Various  useful  local  applications  have  been  already 
alluded  to  in  the  treatment  of  this  affection.  Intra-uterine  medi- 
cation and  the  different  methods  of  applying  absorbent,  emollient, 
stimulant  and  caustic  remedies  to  the  uterine  cavity  have  been 
referred  to.  The  special  dangers  of  intra-uterine  injections  have 
also  been  pointed  out.  Any  or  every  form  of  local  application  will 
fail  in  some  long-existing  cases  of  corporeal  endometritis.  In 
practice  the  following  are  the  most  efficient  methods  of  treatment 
of  corporeal  endometritis. 

1.  Constitutional  treatment,  such  as  that  indicated  in  endo- 
cervicitis. 

2.  Dilatation  of  the  internal  os  with  dilators  or  tents. 

3.  Curettage,  followed  by  the  application  of  chromic  acid,  espe- 
cially if  there  be  reason  to  suspect  a  granular  condition,  or  f  ungosities. 

In  an  obstinate  case  of  chronic  endometritis  we  should  at  once 
proceed  to  curette  the  cavity,  and  combine  this  treatment  with 
drainage  and  subsequent  cleansings  as  advised  in  the  directions  for 
the  operation  of  curettage. 

4.  Other  intra-uterine  medication,  especially  carbolic  acid  and 
iodine,  formic  aldehyd,  ichthyol  ten  per  cent,  solution,  extract  of 
hydrastis,  may  first  be  tried. 

5.  The  application  of  nitric  acid  to  the  cavity  of  the  fundus.  I 
regard  this,  after  curettage,  as  the  most  certain  means  of  dealing 
with  the  disease.  It  has,  however,  the  disadvantage  of  cauterization, 
and  its  effects  on  the  endometrium.  I  therefore  rarely  employ  it 
now,  as  curettage  and  chromic  acid  answer  every  purpose — always 
providing  that  the  curettage  he  thorough,  and  that  chromic  acid  in 
solution  be  subsequently  applied. 

6.  Depletion  of  the  cervix. 

7.  The  vaginal  douche,  using  with  it  iodine,  borax,  carbonate  of 
soda,  Kreuznach  water  (the  mother-liquor  of  the  same  spa),  or  that 
of  Woodhall. 

8.  The  persistent  use  of  glycerine  with  hydrastis  and  ichthyol 
tampons. 

9.  If  a  displacement  exist,  rectify  it  and  adjust  a  pessary,  when 
the  inflammatory  state  has  been  treated  for  some  time. 


fNFLA.U.VATIOX  OF  UTEBfNE  TISSUES— ACUTE  AND  CHRONIC.    347 


Zinc  Chloride  Treatment. — The  cauterization  of  the  uterine  canal  with  zinc 
chloride  as  a  means  of  treating  chronic  enlargement  of  the  uterus  has  been 
practised  by  Kheinstiidter,  Dumontpallier,  Fraenkell,  and  others.  The  zinc 
(grs.  XXX. — 3i.  to  the  ounce)  is  applied  twice  in  the  week.  The  vagina 
should  be  carefully  protected,  and  any  of  the  solution  that  may  touch  the 
vaginal  wall  should  be  immediately  neutralized  with  bicarbonate  of  soda. 

The  practitioner  in  using  zinc  chloride  will  find  it  safer  to  adopt  the  pre- 
caution advised  in  the  application  of  all  powerful  intra-uterine  medicaments, 
of  securing  sufficient  patency  of  the  cervical  isthmus,  avoiding  excess  of  the 
solution  applied,  and  giving  due  attention  to  the  time  of  application  as  regards 
the  occurrence  of  the  catamenial  flow.  The  value  of  iodoform  gauze, 
whether  alone  or  combined  with  curetting,  as  an  intra-uterine  dressing  and 
as  a  vaginal  tampon,  I  have  before  alluded  to. 

G-alvano-chemical  Cauterization. 

G.  Apostoli,  of  Paris,  treated  chronic  metritis  by  means  of  the  galvanic 
current,  beginning  with  a  weak  current  at  first  (20  or  30  up  to  80  milliam- 
peres  at  the  first  sitting),  and  gradually  reaching  200  milliamperes.  Ten 
minutes  is  the  time  allowed  for  a  sitting.  The  positive  pole  is  placed  in  the 
uterus  in  bsemorrhagic  and  ulcerative  states,  the  negative  in  other  conditions. 
At  all  sittings  the  strength  of  the  current  is  to  be  increased  gradually,  and,  if 
rest  in  bed  cannot  be  secured,  once  a  week  is  often  enough  to  operate,  other- 
wise twice  weekly.  Coitus  must  not  be  permitted.  Pregnancy  is  to  be  first 
carefully  excluded.  Any  existing  or  recent  perimetritis  ^^^ll  contra-indicate 
the  treatment.     Apostoli  claimed  for  this  method — 

1.  Its  ease  of  application  and  harmlessness. 

2.  The  gradual  nature  of  the  cauteiization,  which  is  always  under  control. 

3.  Its  chemical  as  well  as  caustic  action. 

4.  It  may  be  used  either  to  restrain  haemorrhage  or  reduce  congestion.* 

Syphilitic  Endometritis. 

Syphilis. — The  occasional  relation  of  syphilis  to  chronic  inflammatory  states 
of  the  endometrium  should  not  be  forgotten.  I  can  most  strongly  recom- 
mend the  tannate  of  mercury  in  all  secondary  or  tertiary  sj^hOitic  affections. 
Both  it  and  the  bicyanide  of  mercury  (as  elsewhere  advised)  are  admirable 
preparations  of  mercury  to  administer  to  women.     A  pill  of — 

Hydrarg.  tannatis,  gr.  ss.  to  gr.  i. 
Quinse  sulph.,  gr.  i. 
Ext.  gentian,  q.s., 

to  which,  if  necessary,  jj\  to  J^  of  a  grain  of  arsenious  acid  may  be  added, 
will  be  found  a  most  effectual  remedy  in  chronic  or  recurrent  syphiHtic 
states.  With  either  of  these  preparations  of  mercury,  this  mixture  of  the 
three  iodides  of  potassium,  sodium,  and  ammonium,  may  be  combined.f 

*  Electro-therapeutics:  see  chapter  on  Electro- therapeutics. 
t  See  chapter  on  the  Vulva  for  further  remarks  on  Syphilitic  Conditions  of 
the  Genitalia. 


348  DISEASES  OF   WOMEN. 

Microscopical  Diagnosis  of  Growths  of  the  Cervix  Uteri. 

In  the  face  of  the  difficulty  of  diagnosis  of  morbid  growths  of  the  uterus  by 
means  of  the  microscope,  and  the  various  appearances  presented  at  different 
periods  of  life  by  the  normal  uterine  tissues,  it  is  clear  that  only  experienced 
experts  should  venture  to  decide  upon  the  nature  of  the  tissue  examined  as 
to  its  benign,  tubercular,  or  malignant  character.  Plimmer  *  gives  the  follow- 
ing instructions  as  regards  the  immediate  treatment  of  a  portion  of  tissue 
which  has  to  be  submitted  to^a  further  examination  :  place  first  in  a  solution 
of— 

Sodium  chloride,  7-5  gr. 

Glacial  acetic  acid,  10  c.c. 

Distilled  water,  1  litre. 

Mercuric  chloride  to  saturation. 

Next  wash  in  running  water  for  two  or  three  hours,  and  then  place  in  50  per 
cent,  of  alcohol  for  twenty-four  hours.  After  this,  immerse  in  90  per  cent, 
of  alcohol  for  twenty-four  hours,  and  finally  in  absolute  alcohol  for  twenty- 
four  hours.  This  process  is  pursued  before  the  portion  is  passed  through 
cedar-oil  into  paraffin,  or  cut  with  a  freezing  microtome,  or  a  rocking  or 
paraffin  microtome.  This  method  of  ready  preparation  of  a  specimen  is  one 
at  hand  for  every  one.  It  is  better,  when  possible,  to  cut  out  a  piece  or 
pieces  from  different  parts,  which  shall  include  both  the  mucous  membrane 
and  a  small  portion  of  the  underlying  muscular  layer,  and  when  the  curette 
is  used  for  diagnosis,  the  surface  of  the  muscular  layer  should  be  included. 
In  the  conduct  and  supervision  of  any  case  of  cervical  disease,  whether  it  be 
simple  hyperplasia,  any  form  of  erosion,  hypertrophy,  polypi,  or  adenomatous 
growths,  a  careful  pathological  report  should  be  obtained  as  to  the  nature  of 
the  affected  tissues. 

I  can  only  repeat  here  the  caution,  several  times  reiterated  in 
this  work,  that  in  the  treatment  of  all  suspicious  chronic  enlarge- 
ments of  the  uterus,  we  should  satisfy  ourselves  thoroughly  as  to 
the  condition  of  the  endometrium  by  the  assistance  of  dilatation, 
the  dull  curette,  and  the  microscopy.  These  aids  to  diagnosis 
become  the  more  necessary  when  we  have — 

Cystic  and  follicular  degeneration  of  the  cervix. 
Shreddy  discharges  from  the  uterine  canal. 
Softness  and  tenderness  of  the  uterine  walls. 
Any  foul-smelling  discharge. 
A  recurring  sanious  flow. 

"We  may  also  thus  early  detect  histologically  the  presence  of 
tubercle  or  cancer. 

*  Brit.  Gyn.  Jour.,  Nov.,  1895. 


INFLAMMATION  OF  UTERINE  TISSUES— ACUTE  AND  CHRONIC.    349 


Subinvolution  following  Labour. 

Pathology. — The  entire  organ  is  enlarged,  its  walls  are  tliickened, 
and  its  cavity  increased  in  size.  We  best  understand  the  causes  of 
this  increase  when  we  recollect  the  changes  which  occur  in  the 
tissues — muscular,  cellular,  lymphatic,  and  vascular — of  the  preg- 
nant uterus  from  conception  to  full  term.  The  period  of  complete 
development  is  arrived  at  when  parturition  occurs.  After  labour 
there  is  a  process  of  '  retrograde  metamorphosis,'  when  the  uterus, 
especially  during  the  puerperal  month,  passes  through  the  series  of 
changes  that  constitute  involution.  Absorption  of  debris,  fatty 
degeneration  of  the  muscular  tissue,  and  formation  of  new  elements, 
are  briefly  the  means  by  which  this  change  is  accomplished  and 
completed,  in  a  period  of  from  six  to  eight  weeks.  Should  this 
katabolic  process  be  arrested  from  any  cause,  we  have  an  unabsorbed 
fatty  debris;  enlarged  muscular  fibres,  with  embryonic  elements  of 
new  tissue ;  hypertrophied  areolar  tissue ;  increased  size,  both  of 
the  bloodvessels  and  lymphatics.  While  the  muscular  elements 
remain  thus  stationary,  or  after  a  little  time  commence  to  atrophy, 
there  is  hypertrophy  and  increase  of  the  connective  tissue,  and  the 
uterus  is  arrested  in  a  state  of  general  congestion,  with  enlarged 
vessels.  The  hyperplasia  of  the  muscular  fibres  is  an  essential  part 
of  the  process,  the  augmentation  in  the  connective  tissue  influencing 
it  but  little  (Finn,  St.  Petersburg).  The  number  of  muscular  fibres 
is  always  increased.  There  is  no  clifiiculty  in  understanding  why 
hyperplastic  deposits  and  rapid  development  of  connective  tissue 
follow.  This  hyperplasia  is  the  essential  pathological  condition  of 
the  affection.  As  occurs  elsewhere,  the  connective-tissue  growth 
strangles  the  vessels,  and  consecutive  atrophy  follows.  Change  in 
colour  and  size  of  the  uterus  is  the  result.  The  last  stage  is  one  of 
contraction  and  shrinking. 

Apart  from  pregnancy  and  labour  the  surgeon  often  meets  cases 
in  which,  with  cervical  endometritis,  there  is  considerable  enlarge- 
ment and  subinvolution  of  the  uterus.  In  virgins  we  frequently 
find  considerable  uterine  enlargement,  not  myomatous,  associated 
with  displacement. 

We  constantly  see  patients,  married  and  single,  in  whom  the 
cavity  of  the  uterus  is  enlarged  to  the  extent  of  three  inches  and 
over,  who  are  nulliparous.  Sclerosis  of  the  uterine  parenchyma, 
some  version  or  flexion,  and  a  chronic  endocervicitis  are  present. 
Thus,    chronic    congestion    leading    to    transudation,    hypertrophy. 


'>50 


DISEASES   OF    WOMEN. 


enlargement  of  the  uterus,  hyperplastic  change  with  cellular  tissue 


Fig.  246. — Epithelial  Denudation  around  the  Os  Uteri,  showing  Effects 
OF  Laboce  One  Month  after  Partcbitiox.     (Robert  Barnes.) 


formation,  may,  and  frequently  do,  arise  in  other  ways  than  as  a 
sequence  of  pregnancy. 

Causation.— We  find  most  frequently  the  causes  of  subinvolution 
in  parturition  and  neglect  during  the  puerperal  month  ;  as  standing, 
or  over-exertion  too  soon  after  delivery ;  puerperal  peritonitis,  or 
metritis ;  laceration  of  the  cervix ;  endometritis,  corporeal  and 
cervical,  and  the  causes  which  produce  these  states;  frequent 
pregnancies  ;  prolonged  lactation  ;  versions  and  flexions. 

Diagnosis. — By  digital  examination,  if  the  cervix  be  involved, 
we  detect  a  rather  open  os,  which  is  swollen  and  painful ;  a  sensitive, 
though  somewhat  hard,  cervix,  which  has  descended  in  the  pelvis. 
The  uterus  is  generally  either  abnormally  anteverted  or  retroverted, 
more  frequently  the  former.  By  bimanual  examination  the  body 
of  the  uterus  is  found  enlarged,  and  by  careful  palpation  the  fundus 
is  discovered,  unless  it  be  retroverted,  above  the  pub&s.  The 
uterine  sound  passes  for  the  extent  of  three  or  three  and  a  half 
inches.  The  history  of  the  case,  pointing  either  to  an  old  endo- 
metritis,  a  recent  parturition   or   abortion,  or  irregularity  in  the 


L\  FLAM  MAT/ ox  OF  UTERINE  TISSUES— ACUTE  AND  CHRONIC,    351 


menstrual  flow,  will  confirm  the  diagnosis.  The  chance  of  conception 
and  pregnancy  must  he  carefully  remembered  ;  and  if  any  doubt  exist, 
the  passage  of  the  uterine  sound  should  be  postponed. 

There  are  some  negative  signs  it  is  well  to  remember  in  differen- 
tiating this  affection  from  pregnancy  or  malignancy.  The  cervix 
is  rarely  soft  ;  there  is  no  progressive  enlargement  of  the  uterus 
from  month  to  month  ;  the  uterus  does  not  generally  increase  in 
size  beyond  three  and  a  half  to  four  inches  ;  the  other  signs  and 
symptoms  of  pregnancy  are  absent ;  there  is  not  the  cachexia  of 
cancer  ;  the  discharge,  if  any,  is  not  foul-smelling ;  there  is  not  the 
pain  of  malignant  disease.  With  these  facts  in  our  mind,  we  are 
not  likely  to  mistake  chronic  hyperplasia  for  either  early  pregnancy 
or  cancer  of  the  uterus. 

Symptoms. — Thei'e  is  scarcely  any  symptom,  either  constitutional 
or  local,  attendant  upon  a  utei'ine  affection,  that  a  woman  afflicted 
with  chronic  hyperplasia  of  the  womb  may  not  suffer  from.  To 
enumerate  these  would  be  to  recapitulate  all  the  various  pelvic 
pains  and  reflex  disturbances  which  arise  from  chronic  endometritis. 
The  more  prominent  symptoms  usually  are :  difiiculty  in  walking, 
lumbar  and  sacral  pain,  pelvic  distress  from  pressure  on  the  bladder 
or  rectum,  nausea,  dyspareunia,  loss  of  appetite,  and  various  nervous 
disorders.  If  the  fundus  be  the  part  principally  engaged,  there  is 
very  often  menorrhagia  or  metrorrhagia. 

Treatment. — -If  inflammatory  conditions  of  the  endometrium  are 
present,  these  must  be  treated  in  the  manner  already  indicated. 
This  is  one  of  the  exceptions  in  which  the  hot  vaginal  douche 
(medicated)  is  of  use.  The  uterus  should  at  intervals  be  freely 
depleted,  and  glycerine  and  ichthyol  or  iodized  tampons  used. 

Sexual  intercourse  must  be  avoided.  Weir  Mitchells  rest  plan 
may  be  tried,  in  the  manner  detailed  at  p.  202.  To  those  who  can 
afford  it,  a  course  of  waters  and  baths  at  Kreuznach,  Woodhall  Spa, 
Salsomaggiore,  Kissingen,  or  Ems,  may  be  recommended ;  Schwal- 
bach,  Barreges,  or  Spa,  if  a  ferruginous  spa  is  indicated.  Royat, 
with  its  arsenical  and  iron  water,  and  Bourboule  with  its  stronger 
arsenical  springs,  are  among  the  most  valuable  arsenical  spas  in 
Europe.  At  all  times  change  of  air,  and,  in  the  summer,  temporary 
residence  by  the  seaside — and  no  country  is  more  rich  in  health- 
giving  seacoast  resorts  than  England — will  do  much  to  assist  the 
treatment.  Where  the  patient  cannot  go  to  the  seaside,  the  sea- 
weed-essence arives  an  admirable  salt-water  bath  at  home. 


CHAPTER   XVI. 

EROSION,  GRANULAR  AND  FOLLICULAR 
DEGENERATION  OF  THE  CERVIX. 

Pathology. — The  term  '  ulceration '  of  the  uterus  has  disappeared 
from  the  vocabulary  of  the  gynaecologist.  (This  remark  does  not, 
of  course,  apply  to  the  consequences  of  malignant  and  syphiKtic 
diseases  of  the  cervix.)  The  common  condition  which  was  ordi- 
narily regarded  as  one  of  ulceration  has  been  proved  to  be  nothing 
more  than  a  desquamation  of  the  superficial  epithelial  layer  covering 
the  lips  of  the  os  uteri  and  cervix. 

This  is  attended  by  increased  vascularity  and  growth  of  villous 
prejections,  which  protrude  on  the  surface  under  a  single  layer  of 
epitheHal  cells.  The  bright  spots  seen  within  the  area  of  the 
eroded  or  granular  patch  were  regarded  as  hypertrophied  papillae, 
enlarged  and  highly  vascular.  Thus,  Scanzoni  described  an  '  aph- 
thous '  ei'osion,  in  which  the  mucous  membrane  is  denuded  of 
epitheKum ;  and  Schrceder  included  a  notice  of  '  ulcers '  of  the 
cervix  with  '  erosions,'  and  described  a  papillary  form  of  erosion 
in  which  the  papillae  develope  into  '  granular  elevations.'  According, 
however,  to  Ruge  and  Yeit,  the  raw  surface  is  coA^ered  with  a  single 
layer  of  epithelium,  and  the  supposed  papillary  granulations  are 
neoplastic  formations.  Recesses  are  formed  by  extensions  inwards 
of  the  epithelium,  and  thus  a  papillary  or  villous  appearance  is 
given  to  the  erosion.  Friction,  even  such  as  is  necessitated  in 
wiping  away  the  thick  purulent  secretion  which  is  found  covering 
the  cervix,  causes  bleeding  from  the  superficial  bloodvessels.  This 
state  has  received  the  name  in  this  country  of  '  cock's  comb  '  ulcer 
or  granulation,  but  the  accompanying  change  in  the  follicles  of  the 
cervix  is  not  to  be  lost  sight  of.  The  glands  are  distended,  and  the 
openings  are  gradually  closed,  through  swelling  of  the  adjacent 
tissue  or  the  formation  of  new  connective  tissue.  Cysts  are  formed, 
some  of  which  may  burst  on  the  surface  and  discharge  their 
contents.     This  cystic  degeneration  may  involve  the  entire  cervix. 


PLATE   XX. 


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PLATE   XXI. 


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CURETTINGS    OF    GlANDI'LAR    ENDOMETRITIS — TAKEN    FROM    SAME    CaSE. 

[To  face  p.  352. 


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PLATE   XXIIL 


■Cukettings  froji  a  Case  of  Endometritis  due  to  Gonococcus. 

[To/ace  p.  353. 


EROSION  OF   THE  CERVIX. 


35a 


Plimmer,  in  a  paper  on  '  The  Diagnosis  of  Growths  of  the  Cervix 


Uteri,'  *  says- 


Varieties  of  Erosion. 


'As  regards  the  so-called  "  erosions,"  they  are  characterized  by  the  vaginal 
surface  of  the  cervix,  which  is  normally  covered  hy  siiuamons  epithelium, 
getting  covered  by  more  or  less  cylindrical  epithehum,  which  may  sometimes 
even  dip  a  little  into  the  tissues.  This  condition  is  really  so  like  ectropion 
that  it  is  only  in  a  virgin  uterus  that  it  can  be  easily  differentiated.  A  real 
erosion  in  the  pathological  sense  it  is  not,  but  rather  the  covering  of  a  surface 
with  columnar  epithelium,  which  normally  would  be  covered  with  squamous 
epithelium.  There  is  here  not  much  change  in  the  connective-tissue  stroma, 
and  only  a  small  quantity  of  round-celled  infiltration.  Tlie  dippinu-  of  the 
columnar  epithelium  into  the 
tissues  forms  gland-like  forma- 
tions, which,  however,  are  much 
shorter  than  the  ordinary  cer- 
vical glands.  This  is  the  con- 
dition usually  called  "  erosio 
simplex^  When  this  columnar 
epithelium  sinks  deeper  into  the 
connective-tissue  stroma,  and  is 
raised  to  the  original  level  of 
the  surface,  small  pseudo- 
papillfe  are  fomied ;  this  is  the 
so-called  "  erosio  papiUarin.'" 
Again,  if  the  surface  be  flatter, 
and  more  columnar  epithelium 
is  cut  off  in  the  deeper  parts,  it 
is  called  "  erosio  foUicuJaris" 
But  these  old  distinctions  are 
not  clear,  nor  are  they  ever 
separated  in  a  typical  case,  so  the  characteristics  of  erosion  mentioned  before 
are  better ;  namely,  the  coA^ering  of  a  part  of  the  cervix,  normally  covered 
with  squamous  epithelium,  with  columnar  epithelium  which  dips  more  or  less 
deeply  into  the  connective-tissue  stroma ;  and  characteristic  also  of  "  erosion  " 
is  it  that  this  part  of  the  connective-tissue  stroma,  which  is  normally  free 
from  glands,  has  a  number  of  gland-like  bodies  produced  in  it,  concurrently 
with  the  covering  of  its  surface  with  c^diudrical  epithelium. 

'  There  are  also,  no  doubt,  cancerous  erosions,  but  in  my  opinion  and  in 
that  of  many  Continental  writers  the  relations  of  erosions  to  cancer  have  been 
much  overrated.  Usually,  in  the  cases  in  Avhich  the  "  erosion"  appearances 
described  above  are  seen,  there  will  be  no  cancer  found.' 

Causation. — Erosion  of  the  cervix,  with  cervical  catarrh,  is  per- 
haps the  most  common  of  all  the  diseased  conditions  of  the  uterus 

*  Brit.  Gyn.  Jour.,  Nov.,  1895. 

t  See  chapter  on  Laceration  of  the  Cervix. 

2   A 


Fig. 


247. — Eeosiox  of  the  Cervix  and  Os 
I'teei.     (Authok.)  t 


354  DISEASES   OF   WOMEN. 

which  we  are  called  on  to  treat.  This  does  not  surprise  us,  when 
we  remember  that  it  may  attend  on  all  the  other  congested  states 
of  the  uterus  and  cervix  that  we  meet  with  in  practice :  as,  for 
example,  endometritis,  displacements,  lacerations  of  the  cervix,  and 
vaginitis.  We  fiad  it  present  in  tubercular,  syphilitic,  and  strumous 
constitutions.  It  may  be  induced  or  aggravated  by  the  use  of  a 
pessary.  I  feel  certain  that  this  latter  habit  acts  more  frequently 
as  an  exciting  cause  than  is  generally  thought. 

Symptoms  and  Physical  Signs. — These  will  in  great  measure 
depend  upon  the  degree  to  which  the  uterus  is  involved  in  any 
coexisting  disease,  such  as  endometritis,  hyperplasia,  vaginitis, 
gonorrhoeal  infection.  Coloured  leucorrhceal  discharge,  pain  when 
walking  or  standing,  lumbar  and  sacral  pain,  dyspareunia,  general 
lassitude,  inability  to  undergo  fatigue  or  any  exertion,  and  loss  of 
appetite,  are  among  the  symptoms  most  frequently  complained  of. 
On  digital  examination,  the  os  uteri  feels  soft  and  moist,  and  the 
granular  or  eroded  surface  is  felt  by  the  finger.  The  os  uteri  and 
adjacent  cervix  are  seen  covered  with  a  creamy  discharge,  perhaps 
tinged  with  blood,  When  this  is  wiped  off  Avith  a  little  cotton- 
wool, the  underlying  eroded  or  granular  surface  is  seen.  Frequently 
there  is  a  fissure  of  the  cervix,  the  result  of  an  old  laceration.  The 
OS  and  cervix  bleed  readily  when  they  are  wiped  with  a  sponge  or 
wool.  If  endometritis  coexist,  the  characteristic  discharge  issues 
from  the  os  uteri.  If  there  has  been  gonorrhoea,  the  uterine  dis- 
charge is  purulent,  of  a  dirty  yellow  colour,  covering  the  surface 
of  the  wool  like  a  layer  of  discoloured  cream.  It  has  a  slight  fcetor. 
In  these  cases  also  there  is  accompanying  vaginitis,  and  probably, 
if  the  disease  be  chronic,  an  accompanying  granular  condition  of  the 
vagina. 

Treatment. — There  are  some  general  hints  regarding  the  treat- 
ment of  erosion  of  the  cervix  I  think  it  well  to  emphasize : — 

Give  a  guarded  opinion  in  reply. to  the  question  of  the  patient  or 
friend,  as  to  the  length  of  time  a  severe  erosion  or  granular  condition 
of  the  cervix  will  take  to  heal.  The  afiection,  especially  if  there  be 
any  coexisting  disease  of  the  uterus,  must  be  tedious. 

A  fair  judgment  may  be  formed  from  the  subsidence  of  the  villous 
projections ;  the  disappearance  of  granulations  ;  the  paleness  of  the 
exposed  surface,  and  its  diminished  vascularity  ;  the  diminution  of 
discharge. 

There  is  a  danger  of  over-treating  this,  affection  by  too  frequent 
use  of  caustics  or  astringents.     The  strength  of  every  application 


PLATE   XXIV 


PLATE   XXT 


Section  of  ax  ADExoiiTOMATors  Cervts;,  takex 

FBOM  AN  EkODED  SuEFACE.      ENLARGED  4^  TiMES. 

(Author.) 

PLATE  XXT 

A  Section  fkom 
CLOSE  TO  Centre. 

X  140. 

See  over  page  for 
microscopic  report. 


-S^r> 


Portion  of  Central  Catity.  Enlarged  20 
TniES. — This  shaving  of  tissue  was  taken 
from  a  cervix  which  had  been  previoiisly 
operated  upon,  leaving  a  granulated  surface. 
Examination  was  made  of  a  transverse  sec- 
tion across  the  canal  to  determine  malig- 
nancv.  This  area  shows  an  open  cleft  with 
fimbriated  margins ;  somewhat  like  a  broken- 
down  gland  or  abscess  cavity. 


PLATE   XXVb. 


^Report. — '  Microscopicallj'  the  central  part  consists  of  glandular  tissue  having 
a  benign  arrangement,  i.e.  the  basement  membrane  of  the  various  tubules 
is  intact,  but  there  is  much  degeneration  and  breaking  down  of  the  gland 
structure  as  a  whole.  The  tubules  trespass  into  the  surrounding  fibro- 
muscular  tissue,  and  the  latter  is  characterized  by  its  extreme  vascularity. 
The  numerous  vessels  all  possess  very  thick  walls ;  some  are  quite 
obliterated  by  the  increase  in  thickness  of  the  walls,  having  caused 
occlusion  of  their  lumina.  The  specimen  presents  the  features  of  an  adeno- 
myoma.'     (x  500.) 

[To  face  p.  355. 


EROSION  OF   THE  CERVIX.  355 

must  be  regulated  by  the  severity  of  the  case,  and  determined  by 
the  sui'gical  instinct  of  the  practitioner.  No  routine  rule  of  using 
this  or  that  strength  of  any  agent  should  be  followed. 

As  much  reliance  should  be  placed  on  physiological  rest  and 
soothing  applications  as  on  local  medication. 

Do  not  pronounce  the  case  cured  until  the  surface  has  completely 
healed  and  the  patient  has  been  subsecjuently  under  observation  for 
a  short  time. 

When  a  patient  presents  herself  with  an  eroded  cervical  surface, 
the  first  poiat  for  the  surgeon  to  determine,  and  on  this  not  a 
little  of  his  future  peace  of  mind  and  the  satisfaction  of  his  patient 
will  depend,  is  to  what  extent  the  canal  of  the  uterus  is  involved  in 
the  inflammatory  process.  This  will  demand  a  careful  examination 
of  the  uterus  and  any  discharge  present.  Should  endometritis  to 
any  extent  complicate  the  erosion,  the  uterine  canal  should  be 
forthwith  dilated,  and  the  endometritis  treated.  There  is  no  use 
in  temporizing  with  eroded  states  of  the  cervix  by  repeated  dress- 
ings, or  by  applying  caustics  to  the  external  os  if  there  be  an 
endometritic  discharge  left  to  cause  irritation  of  a  partially  healed 
surface.  It  will  generally  be  found  that  the  most  satisfactory  plan 
is  not  to  dally  over  various  topical  applications,  but  to  at  once 
proceed  to  dilate  the  cervical  canal,  and  treat  the  endometrium  by 
such  applications  as  20  per  cent,  of  formalin  or  the  liniment  of 
iodine.  If  the  endometritic  discharge  be  profuse  or  suppurative  in 
character  a  preliminary  curetting  will  be  advisable.  At  the  same 
time  a  careful  application  of  nitric  acid  should  be  made  to  the 
eroded  surface. 

This  treatment  should  be  followed  by  systematic  dressings  up  to 
the  next  menstrual  period,  and,  after  it  has  passed  over,  another 
inspection  of  the  uterus  should  be  made,  and  any  spots  that  remain 
unhealed  should  be  I'edressed  with  the  acid. 

If  the  uterus  be  displaced,  it  is  wiser  not  to  readjust  it  or  per- 
form a  fixation  operation  until  the  erosion  be  healed,  and  a  suitable 
pessary  can  be  worn  without  risk. 

General  Management.— Avoidance  of  exercise,  interdiction  of  all 
sexual  intercourse,  the  adniinistration  of  such  tonics  as  quinine  and 
arsenic,  mineral  acids  and  bark. 

Vaginal  Douches. — Some  of  the  following  agents  can  be  added  to 
the  water :  borate  of  soda,  boric  acid,  sulpho-carbolate  of  zinc, 
acetate  of  lead,  Condy's  fluid,  carbolic  acid,  alum,  tannin  (^ss.  of 
the  borate  of  soda  and  3i.  of  one  of  the  other  agents  added  to  a 


356 


DISEASES   OF   WOMEN. 


quart  of  v/ater),  perchloride  of   mercury  (5-^),  liquid  extract  of 
hydrastis,  cbinosol,  vasol  iodine,  lysoform. 

Other  Topical  Applications. — Nitrate  of  silver  (the  fused  sticks 
before  referred  to,  or  the  solution  in  different  strengths)  ;  carbolic 
acid  and  glycerine ;  nitric  acid  ;  Richardson's  styptic  colloid ; 
pigment  of  iodine  and  ichthyol  (iodine  gi.,  rectified  spirit  ^i., 
ichthyol  solution  in  glycerine  10  per  cent.,  flexile  collodion  ^ss.)  ; 
chromic  acid    (51.^ — "^i.)  ;   iodoform  ;    perchloride   of    iron    solution 


Fig.  248. — Vagixal,  Utekine,  and  Operating  Insufflator. 

(51. —  5i.  of  glycerine)  ;  chloride  of  zinc  {'^\. — *^i.) ;  liquid  extract  of 
hydrastis  with  glycerine ;  biniodide  of  mercury.  This  latter  prepa- 
ration is  applied  by  first  painting  the  eroded  surface  with  j)er- 
chloride  solution,  and  immediately  washing  the  surface  with  an 
iodide  of  potash  solution,  when  the  red  deposit  of  iodide  of  mercury 
forms  on  the  part. 

Vaginal  tampons  of  glycerine,  borolyptol,  glycothymolin,  glycerine 
and  tannin,  glycerine  and  boric  acid,  glycerine  and  hydrastis ; 
glycerine,  hydrastis,  and  ichthyol ;  iodine  and  glycerine,  chinosol. 
I  do  not  recommend  ointments  of  any  kind. 

The  appliance  in-  Fig.  248  I  had  made  for  me  for  blowing  any 
powder  on  the  cervix,  inside  the  cervical  canal,  and  on  the  surface 
of  the  wound  if  required.  The  powders  "  Loretin  "  and  "  Dermatol  " 
I  have  found  of  service. 

Scarification. — Much  benefit  may  be  derived  by  the  abstraction 
periodically  of  a  little  blood  with  the  uterine  lancet. 

Suppositories. — I  do  not  advise  vaginal  suppositories.  The  best 
are  those  of  belladonna,  opium,  cocaine,  acetate  of  lead,  tannic  acid, 
oxide  of  zinc,  and  iodoform. 

Follicular  Degeneration. — Three  pathological  conditions  of   the 


EROSION  OF  THE  CERVIX. 


357 


OS  uteri  and  cervix  are  closely  allied  to  each  other,  both  in  their 
etiology  and  histology  ;  these  are — follicular  degeneration,  folli- 
cular hypertrophy,  and  mucous  polypi.  All  three  are  sometimes 
associated  with  either  a  congested,  eroded,  or  lacerated  cervix, 
and  eversion  or  '  ectropion '  of  the  lips  of  the  os  uteri.  Con- 
gestion and  hyper- distention  of  the  glands  of  the  cervix  (ovula 
Nabothi)  lead  to  a  general  cystic  condition,  and  the  cysts  either 
rupture,  or  through  hypertrophy  of  the  subjacent  tissue  are  forced 
forwards  in  the  form  of  polypi,  or  form,  in  the  external  vaginal 
surface  of  the  os  uteri,  gray  or  yellow  cystic  projections,  which 
frequently  have  purulent  contents,  but  are  more  usually  filled 
with    colloid  matter.      Sometimes    the    collapse    of    the   follicle    is 


Fig.  249. — Follicular  Degeneration 
AND  Erosion  with  slight  Lacera- 
tion.    (Author.) 


Fig.  24yA. — Sharply  defined  Erosion 
with  Lacerated  Cervix.   (Author.) 


followed  by  a  depression  on  the  surface  of  the  cervix.  This  little 
pit  slowly  disappears.  The  contents  of  the  cysts  are  granules, 
mucous  corpuscles,  and  epithelial  cells ;  they  are  lined  by  a  base- 
ment membrane  (Farre).  If  the  cystic  degeneration  of  the  follicles 
of  either  one  or  both  lips  of  the  os  should  proceed  unchecked,  and 
there  be  an  increase  in  the  connective  tissue  of  the  cervix,  a  state 
of  general  hypertrophy  ensues,  attended  at  times  by  fungous 
growths.  Thus  '  follicular  hypertrophy '  (Schroder)  of  the  ceiwix 
commences  in  follicular  degeneration  and  cyst-formation  :  the  poly- 
poid character  of  the  cystic  growth  being,  in  this  instance,  prevented 
by  the  investing  and  resisting  epitheKum  of  the  vaginal  surface  of 
the  cervix.     Mucous  polypi  are  found  rather  in  elderly  multiparae. 


358 


DISEASES   OF   WOMEN. 


Diagnosis. — The  presence  of  the  numerous  small  cysts,  and  the 
nature  of  their  contents ;  the  appearance  of  the  characteristic 
polypus  protruding  from  the  os ;  the  soft,  cystic-looking,  and 
enlarged  lip,  will  readily  distinguish  the  three  conditions.  Should 
a  cyst  rupture,  and  an  apparent  ulcer  form,  this  softened  state  of 
the  cervix  might  be  mistaken  for  malignant  ulceration.  Such  an 
error  I  have  known  committed  in  a  case  in  which  I  subsequently 
ablated  one  lip  of  the  os  for  cystic  hypertrophy. 


Fig.  25U. — Sharp  Spoon. 

Treatment. — Cysts  must  be  opened  and  curetted,  or  the  contents 
evacuated,  and  chromic  acid,  carbolic  acid,  or  nitric  acid  applied  to 
the  cavity.  A  mucous  polypus  must  be  removed  with  scissors  or 
forceps.  If  we  suspect  the  presence  of  small  polypi  inside  the 
cervix,  the  canal  is  dilated,  and  resort  had  to  the  curette,  forceps, 
or  long  scissors  for  their  removal.  Mtric  acid  or  chromic  acid  may 
be  used  to  destroy  very  small  polypoid  projections  in  the   canal. 


Fig.  251. — Follicular  Hypertrophy 
OF  THE  Cervix — Sectional  View. 
(Pozzi.) 


Fig.  252.— Mucous  Polypi  growing 
from  the  Interior  of  Cervix, 
following  Follicular  Hyper- 
trophy.    (Pozzi.) 


In  very  obstinate  cases  of  cystic  degeneration  and  follicular  hyper- 
trophy, the  diseased  vaginal  portion  of  the  cervix  may  require 
ablation.     {Vide  Amputation  of  Cervix,  p.  302.) 


CHAPTER   XVII. 

PELVIC    INFLAMMATION. 

There  are  three  forms  of  pelvic  inflammcation,  which  might  well 
be  considered  in.  connection  with  each  other  under  the  heading  of 
Perimetric  Inflammation.     These  are — 

1.  Perimetritis. 

2.  Ovaritis. 

3.  Salpingitis. 

Two  of  these,  ovaritis  and  salpingitis,  are  placed  in  this  work 
under  the  portions  devoted  to  affections  of  the  ovaries  and  Fallopian 
tubes.  They  can  be  studied  in  connection  with  other  forms  of 
pelvic  inflammation. 

Perimetritis. — By  perimetritis  we  mean  inflammation  of  the 
pelvic  peritoneum,  and  limited  to  it. 

As  regards  clinical  differentiation  between  perimetritis  and  para- 
metritis, we  must  abandon  any  theoretical  distinction  which,  on 
anatomical  grounds,  has  been  drawn  between  these  conditions. 
I  am  in  full  accord  with  Emmet  and  othei'S,  who  declare  that 
clinically  this  theoretical  distinction  disappears,  and  that  it  is 
impossible  (at  least  in  the  majority  of  cases)  '  to  make  any  dis- 
tinction at  the  bedside.'  I  believe  that  it  is  better  clinically  to 
retain  the  term  perimetritis  alone,  and  include  under  this  head 
any  secondary  inflammation  in  the  cellular  tissue  in  the  neighbour- 
hood of  the  uterus.  This  latter  may  primarily  occur  between  the 
layers  of  the  broad  ligaments,  between  the  bladder  and  uterus, 
between  the  vagina  and  posterior  wall  of  the  uterus.  The  cellular 
tissue  around  the  cervix  may  be  the  original  seat  of  the  inflammatory 
efiusion  or  phlegmon,  yet  we  frequently  have  salpingitis,  ovaritis, 
and  different  degrees  of  pelvic  peritonitis,  with  effusions  in  Douglas' 
pouch  as  a  consequence.  On  the  other  hand,  the  inflammation 
may  commence  in  the  peritoneal  folds  of  the  pelvis,  anteriorly  or 
posteriorly,  and  effusion  may  occur  primarily  inside  the  peritoneal 
cavity,  as  it  often  does  in  the  pouch  of  Douglas.    Here  cellulitis  is  a 


360  DISEASES   OF    WOMEN. 

secondary  result  of  the  pelvic  peritonitis,  and  both  the  serous  linings 
or  folds  and  the  cellular  tissue  of  the  pelvis  are  alike  involved  in 
the  inflammation  and  resulting  effusion.  The  secondary  peritonitis 
may  be  as  limited  or  localized  in  the  case  of  the  primary  cellulitis,  as 
the  secondary  cellulitis  is  in  the  instance  of  the  primary  peritonitis. 

Hardon  has  drawn  a  distinction  between  true  cellulitis  and  the  fulness 
and  hardness  due  to  the  turgescence  and  engorgement  of  the  large  venous 
sinuses  in  the  broad  ligaments  consequent  upon  pressure  and  dragging  of  the 
uterus.  Proper  elevation  of  the  uterus  relieves  this  congestion.  This  venous 
engorgement  points  to  the  facility  with  which,  in  such  cases,  operative  inter- 
ference (Emmet)  occasionally  leads  to  phlebitis  and  septic  sequences. 

The  relation  of  pelvic  cellulitis  to  peritonitis  is  a  matter  of  extreme  im- 
portance. Does  the  cellulitis  precede  the  peritonitis,  or  vice  versa "}  Polk 
first,*  from  a  series  of  observations  made  by  him  in  the  Bellevue  Hospital, 
argued  that  peri-uterine  inflammation  is  a  product  of  salpingitis,  that  the 
celkilitis  is  secondary  to  the  peritonitis.  This  is  the  view  which  was  advanced 
in  previous  additions  of  this  work.  CuUingworth,  in  an  interesting  article,! 
declares  himself  in  favour  of  Polk's  view.  This  is  the  attitude  of  the  majority 
of  modern  gyna3co]ogists  to  this  question. 

I  am  quite  in  accord  with  the  statement  that  '  the  inflammation 
in  the  great  majority  of  cases  begins  in  the  mucous  membrane  of 
the  uteruSj  either  from  septic  absorption  or  the  poison  of  gonorrhoea,' 
or  from  other  infective  cause,  and  have  already  urged  this  view- 
in  dealing  with  the  course  of  metritis  and  endometritis.  Pain  is 
often  absent  in  perimetric  inflammation  until  the  peritoneum  is 
attacked.  The  clinical  axiom  that  '  neither  a  clean  wound  nor  a 
dean  sound  ever  produced  cellulitis '  (the  italics  are  the  author's), 
is  one  I  thoroughly  endorse,  and  it  places  in  its  proper  light  the 
responsibility  resting  on  the  shoulders  of  every  practitioner  who 
uses  the  uterine  sound,  to  see  that  the  sound  itself,  and  the  vagina 
of  his  patient,  are  free  and  clean  from  any  infective  organisms 
before  the  instrument  is  passed  into  the  uterine  cavity. 

'Adhesive  perimetritis,'  says  Matthews  Duncan,  'is  almost  certainly 
second  in  point  of  frequency  among  the  diseases,  of  women,  the  first  position 
being  held  by  uterine  cervical  catarrh ;  in  post-mortem  examinations  of  women 
no  pathological  condition  is  more  frequently  discovered  than  adhesions  between 
the  internal  genital  organs  and  neighbouring  parts,  especially  about  the  ovary.' 

Any  one,  who,  like  the  author,  has  spent  a  considerable  number 
of  years  teaching  in  an  anatomical  theatre,  and  who  has  been 
engaged  in  making  dissections  of  the  female  pelvic  viscera,  will 

*  Transactions  of  the  Association  of  American  Physicians,  1866. 
t  British  Medical  Journal,  Dec.  27,  1890. 


PEL  VIC  IN  FLA  MM  A  TION. 


361 


verify  this  conclusion.  *  I  do  not  exaggerate,'  says  Emmet,  '  when 
I  assert  that  pelvic  cellulitis  is  by  far  the  most  important  disease 
with  which  woman  is  afflicted.' 

Causation. — Perimetric  inflammation  is  constantly  associated  with 
acute  metritis  and  endometritis  ;  ovaritis  ;  salpingitis  ;  septicaemia  ; 
pyo-salpinx  ;  arrest  of  menstruation  (due  to  the  effect  of  cold) ; 
abortion  and  parturition  ;  operations  on  the  uterus  and  vagina  ;  the 
passage  of  the  uterine  sound  ;  the  use  of  tents  ;  gonorrhoea  ;  imper- 
forate hymen  and  concealed  menses ;  ovarian  cysts ;  uterine 
fibroids  ;  tubercle  ;  cancer. 


Micro-Organisms  in  Pelvic  Suppurations. 

Cases  have  been  recorded  by  Hartmann  and  Morax,*  showing  that  acute 
aseptic  peritonitis  maj^  occur.  No 
micro-organisms  could  be  dis- 
covered in  the  sero-fibrinous  fluid 
that  was  examined.  The  same 
authors  f  proved  that  cases  of 
catan'hal  salpingitis,  bydro-sal- 
pingitis,  retro-uterine  bsematocele, 
with  fever,  may  occur  without  the 
presence  of  micro-organisms.  The 
same  is  true  of  a  number  of  cases 
of  suppui'ation  of  the  adnexa,  but 
in  a  large  proportion  of  the  latter 
streptococci  and  gonococci  were 
found. 

In  the  pus  of  suppurations  of  the 
adnexa  are  found  the  streptococcus 
pyogenes  (the  infective  bacterium 
of  puerperal  septicfemia) ;  thegono- 
coccus ;    the  bacterium   coli   com- 
mune ;  the  staphylococcus  aureus ;   yig.  253.— Collection  op  Serdm  i.v  the 
the    bacilli   of    tubercle,    and    the       Peiutoneal     Cavitt  —  Pekimetkitis 
cladothrix  of  actinomycosis.     (See       Sekosa.    (Scheqbdek.) 
chapter  on  Bacteriology.) 

Pathology. — The  division  of  perimetritis  (Matthews  Duncan) 
into  three  kinds— adhesive,  serous,  and  purulent — answers  all 
practical  purposes.  In  the  first  variety  there  is  an  exudation  of 
plastic  lymph  from  the  engorged  and  turgid  peritoneal  vessels. 
This  results  either  in  temporary  adhesions  between  the  pehac 
viscera,  or  in  permanent  adhesions  which  remain  for  the  lifetime 

*  Annales  de  Gyn^.,  xli.,  p.  193,  1894 ;  Schmidt's  Jahrbiicher,  band  245,  1894. 
t  Bee.  de  Chir.,  p.  343,  1894. 


362 


DISEASES   OF   WOMEN. 


of  the  individual,  causing  dragging  and  displacement  of  the  ovaries 
and  Fallopian  tubes,  binding  these  down,  or  connecting  them  with 
each  other  or  with  the  bowel.  These  adhesive  bands  or  membranous 
layers  may  shut  oif  a  collection  of  pus  or  serum,  forming  cyst-like 
cavities.     Such  an  accumulation  is  shown  in  Fig.  253. 

In  the  serous  and  purulent  varieties  there  is  an  exudation  of 
serum  or  pus  into  the  peritoneal  cavity,  which,  naturally,  first 
collects  in  the  most  dependent  situation,  which  is  Douglas'  pouch, 
pushing  upwards  the  coil  of  intestine  which  is  contained  in  it  when 
the  bladder  and  rectum  are  empty.  The  serous  fluid,  as  it 
increases  in  quantity  and  becomes  harder,  may  press  the  uterus 
forwards  against  the  pubes.  At  other  times  the  exudation  occurs 
at  the  sides  of  or  all  around  the  uterus,  and  it  may  rise  over  the 
fundus  of  the  uterus  above  the  pelvic  brim  into  the  abdominal 
cavity.  A  limited  collection  of  serum  or  pus  may  form  between 
coils   of  intestine;    this,   after  absorption    or    rupture,  may   leave 

adhesions  and  inflam- 
matory thickening  of 
the  peritoneum.  The 
quantity  of  pus  which 
may  collect  in  the 
peritoneal  cavity  is 
very  large.  I  have 
drawn  ofi"  nine  pints 
of  pus  from  the  peri- 
toneal cavity. 

Treatment  of  large 
pelvic  abscess  and 
suppurative  peritoni- 
tis by  c  celiotomy  and 
free  flushing  out  of 
the  peritoneal  cavity 
with  an  antiseptic 
solution  is  the  most 
efficient  mode  of  treat- 
ment of  these  cases 
of  pus-accumulation. 

John  Wallace  exemplified,  hj  a  series  of  cases,  the  advantage  of  the 
treatment  of  collections  of  fluid  in  the  peritoneal  cavity  by  opening  and  drain- 
ing with  antiseptic  precautions.  Two  of  bis  diagrams  I  insert  to  sbow  the 
extent  to  wbicb  such  fluid  collections  may  reach  and  yet  be  cured. 


3\  m. 


3b 


38 


^^■?s 

^/ 

D 

I 

V 

Fig.  254.-    (Wallace.) 

Line  of  incision  exposing  anterior  layer  of  broad 
ligament,  with,  numerous  vessels  distributed 
over  it ;  T,  T,  T,  tympany ;  D,  dulness ;  U, 
uterus  displaced  to  left,  fixation  partial.  Cured 
by  abdominal  section  and  drainage. 


PEL V/( '    fNFLA  .I/.I/.l  TfO.W 


:i6X. 


/4  ir\. 


Fig.  254:A.     (Wallace.) 

dull  area  of  tumour ;  T,  T,  tympany ;  U,  uterus 
displaced  downwards  and  to  right  behind  tumour ; 
\,  fixed  with  tumour  to  pelvic  walls.  Cured  by 
abdominal  section  and  drainage. 


It'  not  evacuated  the  pus  may  open  into  the  rectum,  the  vagina, 
the  bladder,  and 
(very  largely)  into 
the  uterus.  It  may 
point  in  the  groin, 
the  upper  part  of 
the  thigh,  in  the 
region  of  the  sciatic 
notch,  or  in  the  lum- 
bar region.  I  have 
seen  cases  which 
have  burst  into  the 
rectum,  vagina, 
bladder,  and  the 
groin. 

A  sudden  escape 
of  pus  into  the 
general  peritoneal  D, 
cavity  is,  as  a  rule, 
followed  by  fatal 
peritonitis,  or  septi- 
cpemia.  In  rare  instances,  absorption  of  a  large  collection  of  fluid 
takes  place,  and  a  tedious  and  anxious  convalescence  follows,  nor 
does  it  happen  without  leaving  an  exudation  and  adhesions  which 
often  resemble  a  circumscribed  tumour  in  the  pelvic  roof. 

Clinical  experience  teaches  us  that  it  is  not  right  in  these  cases 
to  continue  an  expectant  plan  of  treatment  for  any  length  of  time. 
There  is  always  the  risk  of  septic  absorption,  of  secondary  degenera- 
tions in  the  ovaries  and  tubes,  and  various  imprisonments  of  fluid 
effusions  in  the  broad  ligaments  and  elsewhere,  with  matting 
together  of  the  pelvic  structures.  The  pelvis  may  be  explored 
when  it  is  too  late,  and  when  cceliotomy  is  worse  than  useless. 
This  sad  evidence  of  a  policy  of  '  waiting  on  events  '  is  unfortunately 
too  often  seen  as  a  consequence  of  timidity  or  sanguine  reliance  on 
the  vis  medicatrix  naturae. 

Symptoms  and  Physical  Signs. — The  symptoms  will  depend  on 
the  nature  of  the  inflammation,  whether  it  be  acute  or  chronic.  In 
acute  pelvic  peritonitis  there  are  generally  rigors,  high  temperature, 
rapid  pulse,  coated  tongue,  some  gastric  disturbance,  and  vomiting. 
The  symptoms  are  accompanied  by  abdominal  pain,  tenderness,  and 
tympanites.     On  examination  the  abdomen  is  found  very  sensitive 


364  DISEASES  OF   WOMEN. 

to  pressure ;  the  vagina  is  hot,  perhaps  swollen,  and  we  may,  com- 
paratively early  in  the  attack,  be  able  to  define  a  fluctuating  swell- 
ing in  the  posterior  vaginal  cul-de-sac,  or  laterally  through  the 
vaginal  roof.  These  signs  of  the  affection  are  soon  followed  by  the 
characteristic  one  of  fixation  of  the  uterus.  There  is  a  hard  '  board- 
like '  feeling  (Doherty)  anteriorly  or  posteriorly,  the  effusion  dis- 
placing the  uterus,  or  encircling  it.  This  may  rise  to  the  level  of 
the  umbilicus,  and  there  may  be  but  little  fluid  pus  in  the  pelvic 
cavity,  which  is  filled  with  a  sloughing  mass  of  phlegmonous 
exudation.  Should  the  disease  run  an  unfavourable  course,  the 
symptoms  of  septicaemia  or  general  peritonitis  set  in  ;  the  A^omiting 
increases  ;  the  temperature  rises  to  105°  or  106°;  the  pulse  is  rapid 
and  wiry ;  the  countenance  becomes  more  anxious  ;  abdominal 
pain,  tenderness,  and  tympanites  increase,  and  delirium  sets  in. 
In  other  instances  the  perimetritis  is  far  more  insidious  in  its  onset, 
and  the  symptoms  are  so  obscure  that  no  local  examination  is  made 
until  the  exudation  is  discovered,  filling  Douglas's  space  and  fixing 
the  uterus.  Persistent  abdominal  pain  varying  in  severity,  or  some 
pelvic  distress  either  in  the  bladder  or  rectum,  first  calls  for  an  ex- 
amination, and  the  swelling  is  discovered.  Such  cases  may  run  on 
for  some  time  before  advice  is  taken,  often  as  much  for  the  loss  of 
appetite  and  wasting  as  for  the  local  distress.  A  case  is  assumed  to  be 
one  of  threatening  typhoid,  or  some  'gastric'  disturbance  with  hyper- 
pyrexia, and  is  treated  accordingly,  until  the  more  pronounced  local 
symptoms  and  signs  arouse  suspicion,  attention,  and  examination. 

Appendicitis."' — The  association  of  appendicitis  with  affections 
of  the  internal  genitalia  has  been  fully  discussed.  In  the  onset  of 
the  inflammation  an  attack  of  appendicitis  is  liable  to  be  mistaken 
for  pelvic  peritonitis  or  vice  versa.  There  is  some  excuse  for 
this  in  the  severe  pain  which  is  complained  of  low  down  in  the 
iliac  region,  and  the  rise  of  temperature.  The  sickness,  the  intense 
inguinal  pain,  the  sensitiveness  and  swelling  in  this  region,  the 
constipation,  the  early  tendency  to  tympanites,  the  greater  general 
distress,  the  history  of  previous  attacks,  and  the  negative  evidence 
afforded  by  a  vaginal  and  rectal  examination,  the  chance  of  such  an 
error  being  remembered,  should  not  leave  any  doubt  as  to  the 
presence  of  the  bowel  complication.  I  cannot  refrain  here  from 
urging  the  gravest  need  for  caution  in  arriving  at  early  diagnosis 
of  these  cases  of  appendicitis  and  typhlitis,  or  perityphlitis,     I  have 

*  See  p.  41 ;  also  chapters  on  Salpingitis,  Pyo-salpinx,  and  Myomata  for 
appendical  complications. 


PEL  VIC  TNFLAMMA  TION. 


365 


UTERUS 


seen  some  most  regrettable  and  fatal  errors  made  in  this  respect. 
In  some  cases  the  symptoms  of  appendicitis,  obscure  at  first,  run  on 
very  rapidly  after 
some  forty -eight  hours, 
and  operati\"e  assis- 
tance may  thus  be 
deferred  until  it  is  too 
late.  Of  all  the  acute 
inflammations  occur- 
ring in  the  abdomen 
or  pelvis,  that  which 
involves  the  greatest 
responsibility,  if  an 
expectant  or  tempo- 
rizing attitude  be  as- 
sumed, is  appendicitis. 

A  practical  and  clinical 
di-\nsion  of  appendicitis  is 
that  of  James  Swayn,  who 
divided  appendicitis  into 
simple,  plastic,  suppura- 
tive, and  relapsing.  He 
makes  with  reference  to 
the  last  these  important 
remarks : 

'  The  next  variety — 
that  of  rapidly  perforative 
or  fulmiuative  appendi- 
citis— is  more  common  in 
young  people,  and  is  the 
most  fatal  of  any  form. 
Its  seriousness  is  shown 
by  the  fact  that  in  at 
least  75  per  cent,  of  per- 
forative cases  it  was  the 
first  attack  which  was 
accompanied  by  the  per- 
foration. The  strangu- 
latiou  of  the  appendix  in 


APPENDIX 


I         CAECUM 

Fig.  25.5. — Showixg  AnnEsiox  of  Old  Pedicle  of 
Kemoved  Adxex.v  adheeext  to  C^cvm  and 
Appendix.     (A.  Smith.) 

The  above  drawing  is  taken  from  a  case  of  Albert 
Smith's.  The  right  adnexa  were  removed,  but 
pain  still  continued.  Coeliotomy  was  again  per- 
formed eight  months  subsequently,  when  the  ad- 
herent caecum  was  separated  from  the  pedicle, 
and  the  left  adnexa  removed.  Symptoms  still 
continuing,  six  months  after  the  second  operation 
coeliotomy  revealed  the  condition  as  shown  in  the 
drawing — a  turgescent  vermiformix.  and  an  ulce- 
rating cavity  formed  by  the  end  of  the  old  pedicle, 
the  caecum,  and  the  vermiform  appendix.  The 
ulceration  was  of  a  tubercular  nature.  Eemoval 
of  the  appendix  and  all  the  ulcerating  surface, 
together  with  the  remains  of  the  old  stump, 
effected  a  complete  and  permanent  cure. 


the  way  already  explained 
is  most  complete,  and  rapidlj'  runs  on  to  gangTcne  of  its  walls,  which  then 
become  perforated,  with  the  rapid  diffusion  of  the  septic  contents  over  the 
peritoneal  cavity.  Perforation  does  not  usually  occur  until  the  second  or 
third  day,  being  preceded  by  the  general  and  local  pains  and  vomiting,  as  in 
other  varieties.    The  temperatme  is  not  at  first  much  raised.    With  the  onset  of 


366  DISEASES   OF   WOMEN. 

perforation  the  symptoms  assume  all  the  gi'avity  of  an  acute  general  peritonitis. 
The  pain,  especially  in  the  right  iliac  fossa,  is  more  intense,  and  rapidly 
spreads  over  the  whole  abdomen,  the  vomiting  becomes  incessant,  constipation 
is  practically  absolute,  and  the  pulse  is  small  and  frequent.  The  general  symp- 
toms are  at  first  those  of  shock,  and  the  temperature  may  be  low,  although  it 
subsequently  rises  to  102°  or  more  if  the  patient  should  live  for  any  length  of 
time.  The  abdomen  is  at  first  retracted,  and  the  abdominal  muscles  very  tense, 
but  later  on  there  may  be  general  abdominal  distension  from  paralysis  of  the 
intestines.  The  face  bears  the  usual  anxious  expression  of  acute  abdominal 
disease.  The  patient  may  die  in  a  day  or  two,  apparently  from  a  general  septic 
condition,  before  much  suppuration  has  occurred  ;  in  some  cases  she  may  drag 
on  for  a  fortnight  or  more,  but  eventually  she  dies  of  a  general  suppurative 
peritonitis.     According  to  Fitz,*  98  out  of  176  cases  died  in  the  first  week.' 

Prognosis. — Perimetritis  is  always  a  dangerous  and  serious  affec- 
tion. The  principal  dangers  are :  general  peritonitis,  phlegmon  of 
the  pelvic  cellular  tissue,  pelvic  abscess  and  septicsemia,  metritis, 
uterine  displacements,  and,  as  secondary  results,  limited  organized 
effusion,  adhesion,  atrophic  states  of  the  ovaries,  obliteration  of  the 
tubes,  dysmenorrhcea,  and  sterility. 

Treatment. — The  immediate  steps  to  be  taken  in  a  case  of  pelvic 
inflammation  will  entirely  depend  on  the  cause  of  the  affection  and  the 
complications  that  are  met  with.  In  the  acute  stage  it  will  depend 
on  the  course  the  inflammation  has  followed  and  the  pelvic  develop- 
ments :  opium  in  grain  doses ;  an  ice-bag  on  the  abdomen  ;  the 
application  of  Leiter's  temperatui-e-regulators;  leeches  to  the  hypogas- 
trium ;  enemata ;  relief  of  the  bladder  by  the  catheter,  if  necessary. 

In  chronic  cases,  avoidance  of  chills  and  exposure  to  cold ;  great 
care  at  the  menstrual  periods  ;  rest  in  bed  should  there  be  periodical 
exacerbations  of  temperature  and  swellings ;  sexual  intercourse 
should  be  prohibited.  Resort  may  be  had  to  warm  hip  and 
iodine  baths,  applications  of  iodine  externally  (iodine  pigment,  made 
of  iodine,  5i.,  mastich  ^i.,  rect.  spt.  ^i.),  warm  compresses,  the  hot 
vaginal  douche,  with  laudanum  added  to  the  water.  A  few  leeches, 
when  the  patient  is  threatened  with  recurrence  of  attacks,  may  be 
applied  near  the  anus  or  in  the  vaginal  region.  The  bromides,  with 
iodide  of  potassium,  are  indicated ;  and,  if  sickness  occur,  such 
medicines  as  oxalate  of  cerium,  bismuth,  hydrocyanic  acid,  chloride 
of  calcium,  or  effervescing  mixtui'es  of  bicarbonate  of  soda  and 
potash,  may  be  given.  Dry  champagne,  or  small  doses  of  brandy, 
with  soda  or  seltzer  water,  are  perhaps  the  best  stimulants  to  select. 
These  should  be  given  in  very  moderate  quantities,  and  abandoned 
when  the  occasion  for  their  employmetit  has  passed. 
*  Am.  J.  M.  Sc,  vol.  xxii.,  1886,  p.  321. 


PELVIC    INFLAMMATION.  367 


To  Sanger  *  we  are  indebted  for  the  following  comprehensive 
classification  of  all  operative  procedures  : — 

1.  Operations  tlirough  the  vagina. 

{a)  Anterior  colpocoeliotomy. 
{h)  Posterior  colpocceliotomy. 

(c)  Anterior  and   posterior   colpocoeliotomy   combined  with    uiii-    or 

bilateral  salpingo-oopliorectomy. 

(d)  Colpohysterectomy. 

(e)  Colpo-hystero-salpingo-oophorectomy,   '  radical  operation  tln-ongh 

the  vagina.'  f 

2.  Abdominal  operations. 

(a)  Uni-  or  bilateral  ccelio-salpingectomy  and  coelio-salpingo-oopho- 
rectomy. 

(6)  Total  coelio-salpingo-oophoro-hysterectomy  (radical  abdominal 
operation). 

(c)  Bilateral  ccelio-salpingo-oophorectomy  combined  with  supra- 
vaginal hysterectomy. 

3.  Abdomino-vaginal  hystero-salpingo-oophorectoray,  commenced  generallj' 
through  the  vagina,  and  ending  by  abdominal  section. 

4.  Sacral  or  parasacral  coeliotomJ^     This  operation  we  need  hardly  consider. 

Bouilly  urges  that  in  acute  pelvic  abscess  and  primitive  peritoneal  connec- 
tions, as  also  in  encysted  abscess  of  the  appendages,  incision,  followed  by 
drainage,  frequently  cures,  and  that  vaginal  punction  does  not  interfere  with 
the  subsequent  hysterectomy,  if  such  a  step  be  demanded.  The  unilateral  or 
bilateral  character  of  the  adhesions,  the  height  in  the  pelvis  to  which  the 
purulent  collection  extends,  the  degree  of  adhesion  of  a  suppurating  sac  to 
the  uterus,  must  be  the  principal  guides  to  the  choice  of  one  of  the  two  steps, 
coeliotomy  or  vaginal  h}^sterectom3\  The  latter  operation,  he  says,  has  the 
advantage  of  being  more  radical  in  character,  and  provides  more  perfect 
di'ainage,  while  the  utero-adnexal  castration  affords  the  most  complete  pro- 
tection agaujst  any  associated  subsequent  complications. 

This  conclusion  of  Bouilly's  must  be  accepted  as  applying  generally  to 
pelvic  suppurative  conditions.  In  certain  cases  the  abdominal  route  is,  in 
my  opinion  on  many  grounds,  that  by  which  we  can  operate  most  safely, 
thoroughly,  and  expeditiously.  The  local  conditions  and  complications  in 
the  individual  case  under  consideration  will  guide  the  surgeon  in  his  choice 
of  route.  Only  a  most  exhaustive  examination  under  anaesthesia  can  deter- 
mine what  these  conditions  are. 

*  Genevi  Medical  Congress,  Proceedings,  1896. 

t  Removal  of  the  Uterus  in  Pelvic  Suppuration. — From  the  persistence  of  the 
gonococcus  infection  in  the  uterus,  the  continuance  of  menstruation,  the  possible 
though  improbable  occurrence  of  cancer  in  the  uterus,  the  advantages  through 
drainage  of  the  operation  itself,  and  the  absence  of  any  sexual  effect,  INIatthew 
Manu  advocates  the  removal  of  the  uterus  with  the  adnexa  in  cases  of  salpingo- 
oophorectomy  for  pelvic  suppuration.  Noble  is  also  a  warm  advocate  for  hystero- 
salpingo-oophorectomy.     (_Amer.  Gyn.,  July,  1903.) 


368 


DISEASES   OF    WOMEN. 


'  Where,'  says  Kelly,  '  the  ovaries  are  seriously  involved  in  the 
disease,  converted  into  abscess  sacs  or  large  hfematomata,  or  if  they 
be  densely  and  intimately  matted  with  the  inflamed  tubes,  so  that  it 
is  useless  to  attempt  to  save  them,  the  removal  of  all  the  diseased 
organs,  together  with  the  uterus,  is  demanded.  The  tube  and 
ovary  on  the  least  adherent  side  are  first  freed,  the  broad  ligament 
is  tied  off,  the  bladder  pushed  down,  and  the  uterine  arteries  secured. 
The  cervix  is  cut  across,  and  the  opposite  uterine  vessels  on  the  more 
difiicult  side  are  exposed  and  ligated.  Finally,  the  round  ligament 
of  that  side  is  caught  and  divided.  The  remaining  tube  and  ovary 
may  now  be  enucleated  by  peeling  them  out  from  below  upwards  with 
the  fingers,  and  then  completing  the  enucleation,  or  if  the  adnexa  on 
the  difiicult  side  are  densely  adherent  and  very  difiicult  to  enucleate, 
the  uterus  is  clamped  at  its  cornu  and  removed  with  one  tube  and 
ovary,  when,  the  pelvis  being  thus  emptied,  more  room  is  obtained  to 
deal  with  the  remaining  embedded  adnexa. 

In  more  difiicult  cases  still,  complicated  by  pelvic  abscesses  and 
general  adhesions,  while  the  uterus  itself  is  buried  in  a  mass  of  these 


Fig.    256. — Kelly's   Operation   tor    Oophoro-salpingo   Hysterectomy   ix 

Qases  op  Extensive  Adhesions  and  Serious  Adnexal  Complications. 

The  uterus  is  bisected  and  amputated  at  the  cervix,  and  the  tubo-ovarian 

vessels  and  the  round  ligaments  are  ligated. 

latter,   the  steps  of  the  operation   are    as  follows; — The    bladder 
and    rectum   are  carefully  separated,  and  any  abscesses,  cysts,  or 


PELVrC  INFLAMMATION. 


"S69 


hfematomata  aspirated  or  punctured,  after  which  the  abdominal  cavity 
is  packed  ofiF  from  the  pelvis.  The  next  step  is  the  incision  of  the 
uterus  in  the  middle  line  antro-posteriorly,  at  the  same  time  that  the 
cornua  are  pulled  up  and  drawn  apart.  By  the  aid  of  Museau  forceps, 
and  lateral  traction  on  the  uterus,  either  half  is  everted  and  the 
bisection  is  carried  down,  stopping  short  either  at  the  cervix  or 
vagina  according  as  a  supravaginal  or  pan-hysterectomy  operation  is 
determined  on.  If  the  former,  the  cervix  is  divided  on  one  side, 
after  which  the  uterine  vessels  are  secured,  then  the  round  ligament, 
and  finally  the  tubo-ovarian.  Thus  one  half  of  the  uterus  is  removed. 
The  opposite  side  is  dealt  with  in  the  same  manner,  or  clamps  may 
be  temporarily  applied.  Free  space  is  now  lefb  for  careful  dissec- 
tion and  enucleation  of  both  adnexa,  should  these  not  have  been 


Fig.  2.56a. — Utekus  removed — The  Vessels  Ligated — Bukied  Sutcees  passe]> 
TO  unite  the  Peritoneum  over  the  Cervical  Stump.     (Howard  Kelly.) 


removed  with  the  uterine  halves.  If  pan-hysterectomy  be  the 
operation  chosen,  the  bisection  is  carried  well  into  the  vagina. 
The  cervix  must  be  very  cautiously  severed  with  modei-ated 
traction  on  the  uterus.  If  the  bladder  be  pushed  down  while  the 
divided  cervix  is  pulled  apart,  the  bisection  may  be  continued 
behind    the   vesico-uterine   fold,   or,   the    peritoneum    having    been 

2   B 


370  DISEASES   OF   WOMEN. 


incised  from  side  to  side,  the  cervix  is  bared  by  pushing  it  down  in 
the  usual  manner.  Should  the  rectum  be  completely  adherent 
behind  to  the  uterus,  the  anterior  face  of  the  latter  is  bisected,  the 
cervix  divided  horizontally,  the  uterine  vessels  caught,  and  a  careful 
division  of  the  posterior  wall  of  the  uterus  then  made  from  below  up, 
a  piece  of  uterine  tissue  being  left  adherent  to  the  rectum  rather 
than  endanger  the  bowel  by  tearing. 

Puncture  through  the  Vagina. 

Howard  Kelly  urges  the  low  mortality  of  the  treatment  by 
puncture  through  the  vagina,  and  the  freedom  from  the  dangers  and 
risks  inseparable  from  the  major  operations.  His  dictum,  however, 
that  '  in  young  married  or  unmarried  women,  in  the  case  of  girls  who 
have  not  come  to  maturity,  even  seriously  diseased  organs  should  not  he 
removed,  until  every  other  means  of  cure  has  failed,^  must  be  accepted 
with  considerable  reserve.  To  wait  until  all  the  other  resources  of 
medicine  and  surgery  have  been  tried  before  proceeding  to  remove 
a  '  seriously  diseased '  organ,  is  to  undertake  a  responsibility  few 
modern  surgeons  would  care  to  accept. 

As  I  have  already  emphasized,  no  possible  precaution  must  be 
overlooked  both  before,  during,  and  after  an  exploratory  or  evacua- 
tion operation,  regarding  asepsis  of  the  vagina. 

The  rectum,  bladder,  uterine  arteries  and  ureters,  have  to  be 
carefully  avoided.  Should  the  peritoneum  not  have  been  opened, 
the  abscess  cavity  is  irrigated  with  sterilized  chloride  of  sodium,  or 
weak  formalin  solution.  The  cavity  is  wiped  clean  with  mops  of 
sterilized  iodoform  gauze,  and  then  drained  with  iodoform  gauze  or 
a  soft  sterilized  tube. 

In  pyosalpinx  I  lean  to  the  side  of  ccelio-salpingo-oophorectomy, 
and,  if  the  uterus  be  at  the  same  time  seriously  involved,  I  have  no 
hesitation  in  saying  that  I  regard  the  operation  of  coelio-hystero- 
salpingo-oophorectomy  as  the  classical  one.  Here  the  uterus  and 
adnexa  are  removed.  The  operation  often  involves  the  greatest 
difficulty  in  consequence  of  adhesions  and  the  septic  state  of  the 
organs.  Therefore,  it  is  one  in  which  no  desire  for  speed  can 
excuse  incomplete  asepsis  and  hsemostasis,  abdominal  and  vaginal ; 
the  careful  adjustment  of  the  peritoneal  edges  and  the  provision  for 
vaginal  drainage.  The  operation  is  completely  described  in  the 
chapter  on  hysterectomy. 

On  the  question  of  drainage,  Sanger  gave  the  following  indications  for  its 
indispensable  employment : — 


PELVIC   INFLAMMATION.  371 


{a)  Every  tiuie  that  virulent  jms  lias  contaminated  tlie  operator's  hand  or 
the  unimpaired  part  of  the  abdomen. 

(J))  lOvery  time  that  the  heemostasis  is  not  perfect,  especially  when  there  is 
a  discharge  of  virulent  pus. 

(c)  In  the  case  of  the  existence  of  a  fistula  before  the  operation,  or  of  per- 
foration of  the  intestine  happening  during  the  operation,  or  likely  to  happen 
afterwards.  Every  time  also  when  fistulse  or  perforations  have  been  closed 
by  the  suture. 

Sanger  lays  down  the  rule  that  coeliotomy  is  always  indicated  in  large 
purulent  collections  and  in  suppurative  cystic  neoi)lasms,  and  the  concert  of 
opinion  of  German 'gynecologists  is  distinctly  in  favour  of  ablation  of  all 
suppurated  organs.  This  is  the  practice  of  A.  Martin,  the  Landaus,  and 
Schauta.  The  vaginal  operation  has  gradually  superseded  the  abdominal 
route  in  most  of  the  Continental  clinics.  A  divergence  of  opinion,  however, 
still  exists  as  between  the  radical  operation  through  the  vagina,  and  abdo- 
minal salpingo-oophorectomy  or  hystero-salpingo-oophorectomy.  After  con- 
trasting the  vaginal  and  abdominal  operations,  Sanger  makes  these  remarks  : — 
'  The  vaginal  operation,  perhaps  less  radical  than  the  abdominal,  is,  how- 
ever, infinitely  simpler  and  far  less  dangerous  in  its  execution ;  it  must  be 
considered  as  the  one  to  be  selected. 

'  Every  time  that  preservation  is  not  indicated,  the  supra-vaginal  ctelio- 
salpingo-oophoro-hysterectomy  will  be  the  least  dangerous  radical  operation. 
'  It  can  even  be  performed  while  preserving  parts  of  the  ovaries.' 
In  considering  the  cases  in  which  a  radical  operation  is  indispensable,  he 
himself  prefers  the  abdominal  method,  and  finally  concludes  : — 

'  Advocates  of  the  different  operative  methods  should  avoid  claiming  aio 
absolute  superiority  for  their  own  proceeding.  Various  methods  laay  he 
justified,  and  in  each  indicidual  case  it  is  far  better  to  taJce  into  serious  con- 
sideration the  special  advantages  offered^  hy  each  one  of  the  methods.'' 

Leopold,  in  advocating  hystero-salpingo-oophorectomy  in  chronic  suppura- 
tive conditions  of  the  adnexa,  with  associated  diseased  states  of  the  uterus, 
refers  to  the  conditions  that  indicate  this  radical  step  : — 

(a)  Where  the  patient  is  deprived  of  all  enjoyment  of  life  and  capacity  for 
work.  (6)  Where  all  ordinary  and  extraordinary  therapeutic  measures  have 
failed,  (c)  When  the  pathological  conditions  include  such  states  as  the  fol- 
lowing :  A  retroflexed  and  adherent  uterus,  enlarged  by  chronic  metritis  and 
endometritis.  Muco-purulent  discharge  from  the  uterus,  or  possibly  periodical 
severe  metrorrhagia.  Salpingitis  and  pyo-salpinx,  and  diseased  conditions  of 
the  ovaries.     Such  states  are  easily  determined  by  a  thorough  examination. 

Leopold  thus  enumerates  the  advantages  of  total  extirpation  by  the  vagina  : 
— (1)  The  complete  removal  of  the  diseased  organs,  without  leaving  behind  a 
still  inflamed  uterus  as  a  focus  of  further  mischief.  (2)  The  wound  is  at  the 
lowest  part  of  the  abdominal  cavity,  favouring  drainage.  (3)  The  operation 
field  is  readily  accessible,  even  in  non-parous  women,  and  in  cases  of 
large  sw^ellings  of  the  appendages.  (4)  There  is  no  abdominal  wound,  and 
the  risk  of  ventral  hernia  is  obviated.  (5)  The  operation  is  much  less 
dangerous  than  laparotomy ;  the  intestines  do  not  come  into  view ;  the 
soiling   of  intestines   with   pus   is   prevented,    the    operation   is    practically 


372  DISEASES   OF   WOMEN. 


extra-peritoneal,  and,  lastly,  it  is   available   for   patients   in   such   a  weak 
condition  that  laparotomy  would  almost  certainly  prove  fatal. 

Peri-uterine  Phlegmon  (Parametritis). 

For  clinical  reasons  rather  than  on  strict  pathological  grounds,  I 
still  consider  under  a  separate  head  the  condition  here  described 
as  '  uterine  phlegmon.'  By  the  term  '  parametritis '  we  mean  a 
phlegmonous  inflammation  of  the  connective  tissue  of  the  pelvis. 

Causation. — It  occurs  often  in  association  with  the  puerperal 
states  as  the  result  of  septic  absorption.  The  proportion  of  cases 
of  peri-uterine  inflammation  due  to  child-bearing,  miscarriage, 
abortion,  both  criminal  and  other,  is  understood  if  we  place  these 
aflTections  as  furnishing  over  50  per  cent,  of  the  causes. 

It  may  also  be  due  to  traumatic  causes,  as  operations  on  the 
uterus  ;  the  use  of  tents,  intra-uterine  stems,  and  medication ;  it 
may  be  a  sequel  to  hysterectomy,  and  attend  as  a  complication  of 
ovaritis  and  salpingitis. 

Pathological  Anatomy. — The  extensive  distribution  and  connec- 
tions of  the  cellular  tissue  of  the  pelvis  explain  the  different 
positions  in  which  the  exudation  occurs  in  parametritis.  This  may 
be  in  the  layers  of  the  broad  ligaments  behind  the  uterus  and 
rectum,  or  extend  upwards  along  the  psoas  muscle  to  the  kidney  or 
into  the  iliac  fossa,  and  occasionally  occur  between  the  rectum  and 
uterus,  the  uterus  and  bladder,  and  downwards  into  the  cellular 
tissue  of  the  gluteal  region  by  the  sciatic  notch.  The  adnexa  are 
necessarily  involved. 

The  stages  of  the  inflammation  are  the  same  as  those  of  phlegmon 
occurring  elsewhere — (a)  congestion,  (h)  effusion,  and  (should  reso- 
lution not  occur)  (c)  suppuration.  The  inflammation  may  not  pass 
beyond  the  second  stage.  With  regard  to  the  exudation,  there  are 
many  degrees  of  intensity,  from  a  slight  swelling  in  either  broad 
ligament  to  a  considerable  infiltration  at  both  sides  or  in  front  of 
the  uterus,  leaving  a  hard  mass  that  fills  the  entire  upper  part  of 
the  pelvis.  The  uterus  is  pushed  to  either  side,  out  of  position,  or 
pressed  downwards,  forwards,  or  backwards.  The  effusion  at  first 
feels  doughy  to  the  finger ;  it  then  gradually  hardens,  and  if  an 
abscess  form,  it  again  softens,  and  fluctuation  rnay  be  detected. 
Though  the  uterus  is  at  first  pushed  to  the  opposite  side,  later  on, 
when  absorption  has  begun,  it  is  draion  to  the  side  of  the  exudation 
(Schrceder).  This  ultimate  traction  of  the  uterus  to  the  side  of  the 
pelvis  in  which  an  old  effusion  has  healed  has  an  important  bearing 


PELVIC   LSI- LAM  MAT  102;.  373 


on  diagnosis.  It  also  explains  the  pain  which  is  specially  com- 
plained of  in  the  contracted  region  through  adhesion  of  the  broad 
ligament  or  ovai'y  of  that  side,  and  displacements  and  entanglements 
of  the  tubes,  or  compression  of  the  ovary,  especially  at  the  left  side, 
by  the  laterally  drawn  uterus  against  the  rectum  or  pelvic  wall. 
And  the  bilateral  character  of  the  pain  is  caused  by  the  tension  of 
the  broad  ligament  of  the  opposite  side,  and  the  dragging  of  the 
ovary  and  possible  stretching  or  torsion  of  the  Fallopian  tube. 
These  are  generally  sad  cases,  for  they  are  difficult  to  alleviate  or 
remedy. 

Diagnosis. — The  most  reliable  points  of  distinction  between 
perimetritis  and  simple  phlegmon  are  set  down  in  tabular  form,  and 
will  help  to  differentiate  these  effusions  from  other  swellings  liable 
to  he  mistaken  for  them  (p.  377).  Easy  though  it  may  seem  to 
the  experienced  hand,  it  is  not  at  all  so  simple  a  matter  for  the 
young  practitioner  to  diagnose  some  chronic  peri-uteiine  exudations, 
especially  those  situated  anteriorly  or  posteriorly,  from  fibroid 
tumours  of  the  uterus.  This  arises  when  the  tumour  cannot  be 
moved  apart  from  the  uterus,  so  that  it  is  difficult  to  isolate  it. 

Symptoms  and  Physical  Signs. — Acute  phlegmonous  inflamma- 
tion is  marked  by  the  following  symptoms :  rigors,  increase  of  tem- 
perature (102°-104°),  rapid  pulse,  pain  in  the  hypogastrium,  general 
febrile  disturbance,  rectal  discomfort  and  constipation  ;  the  vagina 
during  this  stage  is  found  to  be  hot  and  swollen,  and  there  may 
be  vaginal  pulsation.  Later  on  careful  vaginal  and  rectal  explora- 
tion will  enable  the  examiner  to  detect,  in  some  portion  of  the 
vaginal  roof,  or  posteriorly  in  the  utero-rectal  space,  a  painful 
swelling,  the  commencement  of  exudation. 

Quite  recently  I  was  myself  deceived  in  a  case  of  this  kind.  The  jiatient 
had  been  treated  for  uterine  displacement  by  a  distinguished  gynajcologist 
abroad,  and  within  the  same  year  by  a  London  obstetrician  for  the  same 
condition.  Shortly  before  I  saw  her  an  eminent  Loudon  gynaecologist  pro- 
nounced the  case  to  be  one  of  uterine  myoma  ;  another,  that  of  an  inoperable 
malignant  tumour.  I  considered  it  to  be  one  of  myoma,  possibly  degenerat- 
ing. Operation  proved  it  to  be  one  of  pelvic  perimetritic  exudation,  with 
pyo-salpinx  and  extensive  adhesions. 

Later  still,  the  '  board-like '  feeling  of  the  induration  and  the 
displacement  of  the  uterus  and  its  fixed  position  leave  little  room 
for  doubt.  The  decubitus  is  more  frequently  to  the  afiected  side. 
There  is  a  very  characteristic  symptom  which  occurs  also  in  peri- 
metritis— that  is,  retraction  of  the  thigh.     This  happens  when  the 


?74  DISEASES   OF   WOMEN. 


iliac  or  psoas  muscles  are  involved,  and  an  abscess  has  formed,  or 
is  forming,  in  the  neighhourhood  of,  or  involving,  the  psoas  muscle. 

But  perhaps  the  most  vital  fact  for  the  practitioner  to  remember 
is  the  essentially  chronic  and  insidious  nature  of  the  affection  in 
many  instances.  It  is  not  necessary  that  the  patient  should 
complain  of  any  marked  symptom  which  would  attract  the  medical 
man's  attention  specially  to  the  uterus  or  the  pelvic  genital  organs. 
I  have  seen  such  cases  where  pelvic  mischief  was  not  even  suspected. 
I  had  such  a  case,  in  which  dysenteric  symptoms  completely  masked 
those  of  cellulitis,  and  absorbed  the  attention  of  the  physician. 
There  had  been,  in  the  first  instance,  endometritis.  The  patient 
was  unmarried.  When  I  saw  her,  the  uterus  was  quite  fixed  by  an 
exudation,  which  surrounded  it  and  pressed  it  back  against  the 
rectum,  so  that  it  occluded  the  cul-de-sac  of  Douglas  ;  this  explained 
the  rectal  distress. 

Pain  in  walking,  a  throbbing  sensation  in  the  uterus,  general 
loss  of  health,  some  nightly  rise  of  temperature  or  hectic,  may  be 
the  only  symptoms  present  in  these  chronic  cases.  Following  on 
either  the  acute  attack  or  the  chronic  form,  there  is  gradual  wasting 
and  loss  of  weight,  and,  in  some  instances,  emaciation.  The  patient 
is  worn  down  by  the  suffering  and  the  local  distress.  If  the  exuda- 
tion should  terminate  in  suppuration,  and  an  abscess  form,  relief 
may  rapidly  be  afforded  through  its  bursting  or  the  evacuation  of 
the  pus.  Unfortunately,  it  occasionally  happens  that  the  pointing 
of  the  abscess  is  a  matter  of  long  duration  ;  the  pus  burrows  in  the 
cellular  tissue,  and  long  sinuous  channels  form,  through  which  it 
finds  its  way  to  the  surface,  and  these  render  the  case  exti-emely 
protracted.  Such  a  disastrous  series  of  complications  should  not 
be  permitted  to  occur,  in  the  face  of  our  present  knowledge,  by  any 
surgeon. 

The  exudation  may  harden,  and  a  solid  tumour  occupy  some 
portion  of  the  pelvis,  producing  both  rectal  and  bladder  distress 
by  pressure  on  these  viscera,  and  exhausting  the  patient  through 
a  slow  process  of  absorption,  prolonged  over  many  months  of  unrest 
and  suffering.  If  an  abscess  form,  it  may  point  in  the  rectum, 
bladder,  vagina,  or  abdominal  wall. 

In  addition  to  the  immediate  dangers,  from  the  inflammation 
involving  the  peritoneum  and  causing  general  peritonitis,  or  the 
more  remote  risks  that  are  inseparable  from  the  presence  of  pus 
and  the  bursting  of  a  pelvic  abscess,  there  are  the  ultimate  results, 
such  as  adhesions,  atrophy  of  the  ovary,  occlusion  of  the  Eallopian 


PELVTO  INFLAMMATION.  375 


tube,  sterility,  uterine  displacements,  with  amenorrhcea  and  dys- 
menorrhtea.  It  is  not  an  affection  in  which  we  have  so  much  to 
fear  fatal  consequences  as  these  chronic  pathological  and  clinical 
sequel  ?e. 

Treatment. — Most  of  what  has  been  said  regarding  the  treatment 
of  perimetritis  refers  with  equal  force  to  peri-uterine  phlegmon ; 
we  must  advise  rest  in  every  way  that  it  can  be  secured,  and  that 
for  a  considerable  time ;  opium  in  the  acute  stages,  and  the 
regulation  of  the  temperature  by  the  application  of  ice,  or  Leiter's 
irrigator,  which  can  be  applied  both  externally  and  in  the  vagina. 
The  hot  vaginal  douche,  with  a  disinfectant  in  the  water,  used 
three  or  four  times  daily,  and  hot  compresses  or  thin  cataplasms 
applied  externally  and  covered  with  oiled  silk  or  protective,  are 
beneficial.  Light  vesication  over  the  epigastrium  is  useful.  The 
patient's  strength  must  be  sustained  with  a  light  and  nutritious 
diet.  In  the  chronic  stages  the  iodides  of  potassium,  strontium, 
or  sodium,  combined  with  bromides  and  tonics,  may  be  given.  In 
these  cases  of  old  and  unabsorbed  effusion,  the  patient  should  be 
placed  on  a  course  of  perchloride  of  mercury  and  bark,  or  a  pill 
containing  percyanide  of  mercury  (gr.  yy)i  quinine  (gr.  ii.),  extract 
of  gentian  and  bread-crumb  (q.s.) ;  one  pill  three  times  daily.  If 
we  except  the  plan  of  Apostoli  of  treating  parametritis  by  electro- 
lysis, nothing  of  material  importance  has  been  lately  added  to  our 
methods  of  treating  the  earlier  stages  of  this  affection,  and  the 
general  principles  advocated  in  the  text  are  those  by  which  we  must 
be  guided. 

The  various  operative  procedures  that  have  been  referred  to  in 
treating  pelvic  suppurations  are  those  to  be  adopted  in  suppu- 
rating pelvic  phlegmon.  Among  the  more  important  therapeutical 
means  are— 

The  free  use  of  the  hot  douche,  to  favour  resolution  and  promote  absorption. 

Quinine,  antipyrin,  antifebrin,  and  phenacetin  as  antipyretics,  in  the  acute 
stage. 

Careful  cui'etting  of  the  uterus,  after  dilatation,  with  antiseptic  drainage,  if 
there  be  endometritis,  in  the  chronic  stage  of  the  disease. 

The  internal  administration  of  perchloride  of  mercury ;  the  value  of  this 
treatment  was  illustrated  in  previous  editions  of  this  work. 

The  early  evacuation  of  any  serous  fluid  by  the  aspirator,  avoiding  pulsating 
vessels  and  taking  careful  antiseptic  precautions. 

Early  evacuation  of  the  pus  by  the  branched  uterine  dilator.  If  this  be 
present  in  quantity,  and  there  be  multiple  pus  cavities,  the  wound  has  to  be 
enlarged  and  the  finger  introduced  to  break  down  the  septa. 


376  DISEASES   OF   WOMEN. 

Apostoli's" treatment  by  electrolysis  (vide  remarks  on  Gynsecological  Electro- 
Therapeutics). 

I  must  say  a  word  of  caution  regarding  the  rectum.  I  could 
cite  cases  in  which  both  serious  consequences  to  the  patient,  and 
unfortunate  errors  of  diagnosis,  have  resulted  from  overlooking 
concretions  in  the  large  intestine  and  rectum  when  there  were 
perimetritic  exudations  also  pi'esent.  Explore  the  rectum  and  care- 
fully palpate  the  colon  in  every  case  where  a  doubt  exists  as  to  the 
nature  of  an  obscure  abdominal  swelling. 

Hot-air  Treatment. — Scott  Carmichael,*  in  A.  Martin's  klinik  at  Griefswald, 
watched  the  com'se  of  twenty-six  cases  of  parametritis,  paying  special  attention 
to  the  temperature  and  the  leucocyte  count  as  a  means  of  diagnosis  of  sujjpu- 
ration.  Martin  has  this  estimation  of  the  leucocytes  made  regularly  before 
there  is  any  interference,  regarding  it  as  the  most  certain  evidence  of  the 
presence  of  an  abscess.  The  uncertainty  of  the  temperature  indication  makes 
this  test  of  the  more  value.  Should  the  number  of  leucocytes  increase  to 
some  20,000  per  cm.,  it  is  an  indication  for  surgical  interference.  The  treat- 
ment adopted  in  Martin's  klinik  consists  in  the  bringing  about  of  an  active 
hypersemia  by  means  of  hot  air,  which  Bier  f  advocates  as  alleviating  pain, 
promoting  absorption,  loosening  adhesions,  stimulating  general  nutrition  and 
regenerating  processes,  as  well  as  having  a  bactericidal  action ;  also,  in 
recent  cases  the  effect  of  the  hot  air  tends  towards  the  development  of 
suppuration,  and  in  the  more  chronic  ones  to  bring  about  absorption. 
The  mode  of  applying  the  hot-air  treatment  is  as  follows  : — 
'  The  patient  is  placed  in  an  apparatus  having  the  shape  of  a  large  box 
with  two  openings  at  the  lower  end,  through  which  the  thighs  pass,  and  a 
large  opening  at  the  upper  end  for  the  lower  part  of  the  trunk.  The  body  is 
thus  enclosed  from  the  margins  of  the  ribs  above  to  the  knee-joints  below  ; 
thus  the  entire  abdomen  and  pelvis  are  submitted  to  the  action  of  the  hot 
air.  Gas  or  a  spirit  lamp  is  used  to  provide  the  heat,  and  the  temperature  is 
controlled  by  means  of  a  thermometer  inserted  through  the  roof  of  the 
apparatus.  The  sitting  lasts  for  half  an  hour,  the  temperature  having  by 
this  time  reached  from  120^^  to  150°  C.  A'bath  speculum  may  be  introduced 
into  the  vagina,  and  the  patient  is  covered  with  a  loose  nightdress,  which 
can  be  readily  drawn  up.  The  first  sittings  are  not  taken  at  a  temperature 
beyond  100°  to  110°  ,C.  Before  the  patient  is  taken  from  the  bath  the 
temperature  is  allowed  to  cool  down  gradually.  While  in  the  bath  the 
patient  perspires  freely.  The  method  is  simply  the  local  application  of 
the  hot  air  or  Turkish  bath  to  the  abdomen  and  pelvis.' 

In  the  differentiation  of  pelvic  tumours  or  effusions,  the  following 
table  will  be  found  useful : — 

*  Jour.  Obstet.  and  Gyn.  Brit.  JEmp.,  Sept.,  1903. 

t  Therapie  der  Gegenwart,  Feb.,  1902 ;  Eyperiemie  als  Eeilmittel,  Leipzig, 
1903. 


PELVIC  INFLAMMATION. 


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02 

CHAPTER    XVIII. 


PELVIC    HJEMORRHAGE. 


Causation. — It  is  advisable  here  to  consider  briefly  and  separately 
the  occurrence  of  pelvic  haemorrhage,  its  symptomatology  and 
diagnosis,  as  well  as  its  treatment,  general  and  local.  When  we 
come  to  deal  with  the  subject  of  ectopic  gestation,  we  must 
necessarily  discuss  htemori^hage  in  relation  to  gestation,  and  the 
various  pathological  conditions  that  we  associate  with  the  presence 
of  blood  in  the  pelvis,  when  a  gestation  sac  has  ruptured. 

Pelvic  hjematocele  was  a  term  applied  originally  by  McClintock 
(Dublin)  to  a  collection  of   blood,  which  is  either  enclosed  in  the 

peritoneum  behind  the  uterus, 
in  Douglas'  pouch — retro-hsema- 
tocele  (Nelaton) ;  or  in  front 
of  the  uterus  (comparatively 
rare)  ;  between  it  and  the 
bladder  —  ante-lisematocele.  If 
the  blood  escaped  posteriorly 
or  anteriorly  into  the  cellular 
tissue  it  formed  a  h?ematoma, 
by  some  styled  suh-peritoneal 
hsematocele.  If  it  escaped  into 
the  peritoneum,  it  was  called 
intra-peritoneal.  It  is  certain 
that  the  term  '  pelvic  hsema- 
tocele '  has  created  consider- 
able confusion  in  the  minds 
both  of  students  and  prac- 
titioners.* This  has  arisen  in 
consequence  of  its  wide  ap- 
plication to  any  collection  of  intra-pelvic  escape  of  blood,  whether 

*  See  a]so  chapter  on  Ectopic  Gestation,  Tubal  Abortion,  and  Tubal  Eupture. 
The  term  pelvic  hsematocele  is  now  best  restricted  to  an  ectopic  blood-sac. 


Fig.  257. — Eeteo-h^matocele. 
(schrcedee.) 


PELVIC  HEMORRHAGE.  379 

intra-peritoneal  or  otherwise.  Pelvic  haemorrhage  may  occur  from  a 
variety  of  causes.  Thus,  the  bleeding  may  attend  on  pernicious 
antemic  states,  purpura,  malignant  jaundice,  and  during  the  zymotic 
fevers.  It  may  happen  coincidently  with  suppression  of  menstrua- 
tion from  such  causes  as  mental  shock,  exposure  to  cold,  and 
coitus.  It  may  be  the  direct  result  of  such  disease  in  the  ovary  or 
Fallopian  tube  as  may  lead  to  the  rupture  of  either  (see  chapters 
on  Diseases  of  the  Fallopian  Tubes  and  Ovaries).  Traumatism  is 
the  cause  of  the  bleeding  after  operations  on  the  adnexa  and  uterus, 
or  such  direct  violence  as  a  blow,  a  kick,  a  fall,  forcible  dilatation 
of  the  uterus,  and  violent  coitus.  It  may  be  associated  with  atresic 
conditions  in  the  genital  tract  from  the  vulva  to  the  Fallopian 
tubes.  Virchow  and  Schrceder  assigned  as  a  cause  perimetritis  and 
peri-uterine  phlegmon,  though  these  inflammatory  conditions  must 
be  more  frequently  regarded  as  a  consequence  rather  than  as  a 
source  of  the  haemorrhage.  When,  however,  we  come  to  investigate 
the  origin  of  the  haemorrhage,  we  find  in  the  great  proportion  of 
cases  that  it  is  directly  due  to  causes  immediately  connected  with 
conception  and  pregnancy.  Of  these  by  far  the  larger  number 
are  the  result  of  tubal  foetation.  Next  in  frequency  is  abortion, 
and  in  some  rare  cases  the  loss  has  been  brought  about  by  rupture 
of  the  uterus  in  early  pregnancy.  I  prefer  the  inclusive  term 
'  pelvic  haemorrhage,'  though  we  may  retain  the  term  pelvic  hfema- 
toma  to  express  the  fact  that  the  blood  has  escaped  into  the  cellular 
tissue  of  the  pelvis.  We  may,  then,  thus  divide  the  causes  of  pelvic 
haemorrhage  into  two  principal  groups — (a)  that  connected  with 
pregnancy,  by  far  the  most  numerous  ;  and  (6)  miscellaneous. 

Causes  of  Pelvic  Haemorrhage. 

(a)  Connected  with  Pregnancy  : — 

Ectopic  gestation  (pelvic  haematocele). 

Abortion. 

Molar  pregnancy. 

Rupture  of  uterus  (in  early  gestation). 

(b)  Miscellaneous : — 

,,      ,       T  (  Mental  shock. 

Menstrual     suppres-  I  ^  . 
.       „  ^^        I  Coitus. 

sion  from      .  •  ^  , , 

[  Uold. 

Disease  in  the  ovary  (  Leading  to  rupture  of  the  blood  sac 

or  Fallopian  tube    |       in  the  ovary  or  Fallopian  tube. 


380  DISEASES   OF   WOMEN. 


f 


After  operations. 
m  .-  I  Blows,  kicks,  falls,  some  overstrain, 

the  use  of  tents  ;  forcible  dilata- 
tion of  the  cervix ;  excessive  coitus. 

erimetritis    and  [ 

....      /T^.        Often  associated  with  ectopic  cjesta- 
parametritis    ( Vir-  •',         .  .  r     » 


Perimetritis  and 
parametritis  ( Vir- 
chow  and  Schroeder) 


Abnormal    blood- 
states 


Obstruction  to  the 
How  of  blood,  men- 
strual or  other 
(as  in  atresia),  in 
the        . 


tion  or  traumatic  causes. 

Anaemia. 
Plethora. 
Purpura. 
Zymotic  diseases. 
Jaundice. 

Pallopian  tubes. 
Uterus. 
Yagina. 
Vulva. 


Pelvic  hsemorrhage  is  more  likely  to  occur  during  the  active 
period  of  menstrual  life ;  but  I  have  known  a  case  in  which  a 
considerable  escape  of  blood  occurred  from  a  fall  off  a  chair,  in 
a  patient  over  sixty,  and  have  on  one  occasion  seen  a  large  pelvic 
effusion  form  suddenly  in  a  severe  case  of  typhus  fever. 

Symptoms  and  Physical  Signs. — There  may  or  may  not  have 
been  some  previous  hsemorrhagic  discharge  from  the  uterus  or  some 
indication  of  hsemorrhage  such  as  a  feeling  of  faintness,  or  slight 
attacks  of  syncope  attended  by  pelvic  pain.  The  symptoms  in  the 
relative  order,  and  as  they  usually  occur,  are — shock,  tendency  to 
collapse,  great  pelvic  pain,  syncope,  sense  of  weight  and  pressure 
in  the  pelvis,  vomiting,  fall  in  temperature,  rapid  and  weak  pulse. 
These  symptoms  may  persist,  and  death  may  ensue,  despite  every 
effort  to  rouse  the  patient.  They  are  all  intensified  in  the  intra- 
peritoneal variety.  Their  severity  will  in  great  measure  depend  on 
the  quantity  of  blood  which  is  effused  into  the  peritoneal  cavity. 
When  reaction  sets  in  (within  forty-eight  hours),  the  patient  may 
suffer  from  rigors ;  the  temperature  rises,  the  skin  becomes  hot,  the 
pulse  changes  in  character.  The  haemorrhage  may  increase  or 
persist.  On  examination,  the  abdomen  is  frequently  found  tense  ; 
there  is  abdominal  swelling  with  dulness,  especially  over  the 
hypogastric  and  inguinal  regions.  The  abdomen  is  tender  on 
palpation.     On  vaginal    examination,   a   mass    is   found   generally 


PELVIC  HJEMORRHAGE. 


381 


posterior  to  the  uterus — rarely  anterior ;  it  is  smooth,  soft  at  first, 
and  has  a  semi-tluctuating  feeling.  The  uterus  is  pushed  forwards 
against  the  bladder  in  retro-uterine  htemorrhage  ;  backwards  against 
the  rectum  when  the  blood  escapes  anteriorly.  The  bladder  is 
generally  encroached  on,  and  retention  of  urine  or  dysuria  may 
result.  The  rectum  is  compressed.  There  is  either  difficulty  in 
defif cation,  or  rectal  irritation  may  be  present  with  tenesmus  and 
dysenteric  symptoms.  As  the  case  proceeds,  the  uterus  becomes 
more  fixed,  and  the  mass  is  harder.     The  further  symptoms  and 


Fig.  258. — Retko-dterine  HiEsioEKHAGE  (St.  Thomas's  MusErsi)  fkoji 

A  Diseased  Ovary.     (Eubekt  Barnes.) 

It  was  bounded  above  by  plastic  effusions  and  the  small  intestine. 

local  signs  depend  on  the  course  of  the  effusion,  whether  absorption 
occur  or  hardening  of  the  mass.  Should  suppuration  follow,  and  the 
pus  be  not  evacuated,  it  finds  an  exit  through  the  rectum,  vagina, 
or  by  the  bladder.  It  may  escape,  though  rarely,  into  the  peritoneal 
cavity.  On  the  other  hand,  it  may  slowly  disappear  without 
involving  these  viscera.  When  suppuration  takes  place,  we  have 
the  dangers  of  peritonitis,  septic  absorption,  and  septicaemia. 

As  illustrative  of  the  fact  that  cases  in  which  a  considerable  escape  of 
blood  into  the  meso-metrium.  the  result  of  tubal  pregnancy,  may  get  well 
without  interference,  I  may  mention  a  case  in  which  there  was  presumable 
pregnancy  of  the  second  month,  and  an  effusion  that  reached  to  within  a  few 


382  DISEASES   OF    WOMEN. 

inches  of  the  umbilicus.  It  was  ultimately  reduced  to  a  slight  perimetric  hard- 
ness. The  local  treatment  consisted  mainly  in  hot  antiseptic  vaginal  douches, 
and  Leiter's  abdominal  irrigator  applied  externally  charged  with  iced  water. 

I  had  once  a  remarkable  case  under  observation  for  nearly  three  years.  I 
was  telegraphed  for  from  a  distance  to  see  a  young  married  woman  shortly 
after  hsemorrhage  had  suddenly  set  in.  She  had  a  typical  conoidal  cervix 
and  '  pinhole  '  aperture,  and  was  in  acute  pain.  The  bladder  was  pressed 
against  by  the  uterus,  which  was  pushed  upwards  and  forwards,  so  that  it 
was  impossible  to  reach  the  cervix  with  the  finger ;  there  was  retention  of 
urine,  and  with  the  greatest  difficulty  the  rectum  was  occasionally  emptied 
by  enema.  She  was  dangerously  ill  from  the  protracted  pain  and  distress, 
caused  by  the  pressure  of  an  extensive  effusion  on  the  pelvic  nerves  and 
viscera.  This  swelling  gradually  disappeared,  and  when  I  last  saw  her  the 
bowel  and  bladder  acted  in  quite  a  healthy  manner,  and  the  uterus  had  fairly 
regained  its  mobility,  though  not  entirely.  This  case  shows  how  protracted 
such  a  recover}'  may  be. 

Diagnosis.* — ]!^ecessarily  the    most    important    question   is    the 
relation  of  a  pelvic  effusion  of  blood  to  extra-uterine  pregnancy. 
The  difficulty  exists  of  being  able  to  recognize  a  tubal  gestation- 
hsematocele  apart  from  other  causes  of  tubal  hsemorrhage.    As  Falk 
has  pointed  out,  it  is  most  difficult  to  differentiate  rupture,  complete 
abortion  (the  ovum  being  expelled  into  the  abdominal  cavity),  and 
incomplete  abortion,  where  it  remains  in  the  tube.     Clinically,  such 
a  differentiation  is  often  impossible,  nor  can  we  say  when  the  blood 
is   encapsuled.     We  may  be  assisted  in  our  diagnosis,  as  Freund 
has  shown,  if  there  be  undeveloped  mammse,  very  prominent  clitoris, 
and  other  eA'idences  of  cessation  of  pregnancy.     Examination  under 
all  circumstances  must  be  carefully  and  not  too  roughly  conducted. 
We  must  ai-rive  at  a  diagnosis  on  the  following  considerations  : — 
The   history    of   the    case,   the    suppression   of   menstruation, 
previous  proofs  that  conception  has  taken  place,  the  occur- 
rence of  some  operation  or  accident,  the  presence  of  a  zymotic 
disease,  the  evidence  of  pernicious  anaemia,  an  atresia  of  the 
uterus  or  vagina. 
The  suddenness  in   the    accession,   and    the    severity,    of    the 

symptoms. 
The  occurrence  of  hsemorrhage. 
The  position  of  the  tumour  posterior  to    (as  a  rulej,  and  not  at 

the  sides  of  the  uterus. 
The  mode  of  formation  of  the  tumour  ;  its  painful  nature ;  its 
rapid  development ;  its  softness  in  the  first  instance,  and  the 
subsequent  hardness,  accompanied  by  shrinking  of  the  tumour. 
*  See  chapter  on  Ectopic  Gestation  for  the  full  discussion  of  these  points. 


PELVIC  HEMORRHAGE.  383 


The  position  and  size  of  the  uterus,  determined   bimanually 

and  by  the  uterine  sound  ;  the  independent  mobility  of  the 

uterus ;    the    later    appearance    of    pus,   and   the    associated 

reduction  in  the  size  of  the  tumour. 

Prognosis. — This  must  always  be  grave — much  more  so  in  the 

intra-peritoneal    than    the  sub-peritoueal    effusion.      There    is   the 

danger  of  collapse,   exhaustion  from   recurring  haemorrhage ;  pain 

from  pressure  ;  septicaemia,  and  peritonitis. 

Treatment. — Absolute  rest ;  ice  over  the  hypogastrium  ;  ergot 
given  internally,  and,  better  still,  by  means  of  the  subcutaneous 
injections  of  ergotine  or  ergole  (gr.  iii.  to  gr.  v.)  into  the  gluteal 
region  ;  opium  later  on  during  the  period  of  reaction,  both  by  the 
mouth  and  by  the  rectum  (enema  and  suppository)  ;  quinine  with 
digitalis ;  stimulants,  given  by  the  rectum  if  necessary,  to  prevent 
syncope  (iced  champagne  and  brandy  are  perhaps  the  best).  I  have 
already  entered  into  the  question  of  evacuation  of  the  fluid,  and,  in 
order  to  avoid  repetition,  must  refer  the  reader  to  the  chapter  in 
which  this  is  discussed  {vide  pp.  149,  150),  Such  questions  as  the 
death  of  the  foetus,  and  coexistence  of  a  foetal  sac  and  the  urgency 
of  the  symptoms  independently  of  the  h;>^morrhage,  must  decide  the 
question  of  operation. 

Once  it  has  been  determined  that  there  is  a  strong  probability  of 
the  rupture  of  a  tubal  pregnancy,  all  modern  teaching  is  in  the 
direction  of  immediate  cceliotomy.  The  friends  must  at  once  be 
warned  of  this.  Such  a  step  will  depend  upon  the  nature  of  the 
immediate  symptoms,  and  on  the  presence  of  such  constitutional 
conditions  as  persistent  or  variable  high  temperature,  rapidity  of 
pulse,  sickness,  attended  by  local  pain,  and  increase  of  swelling. 
(See  chapter  on  Ectopic  Gestation.) 

This  case  of  pelvic  ha?morrhage  teaches  such  clinical  lessons  that 
I  record  it.     It  is  typical  of  its  kind. 

Large  Tubo-ovarian  Ectopic  Sac  Adherent  Omentum  and  Bowel. 

A  married  woman  aged  thirty-eight  years  had  had  four  pregnancies,  and 
one  miscarriage.  The  youngest  child  was  aged  fifteen  months.  The  cata- 
menia  were  regular  after  the  birth  of  this  child.  The  patient  had  menstruated 
during  previous  pregnancies  for  several  months.  During  the  last  pregnancy 
there  was  prolongation  of  the  catamenia  for  some  months  and  a  'show' 
right  through  the  nine  months.  A  menstrual  period  commenced  at  the 
regidar  time,  but  did  not  terminate  as  usual,  and  there  was  a  constant 
show  for  two  weeks,  during  which  period  she  complamed  of  violent  pain  in 
the  left  iliac  region,  with  constant  nausea  and  attacks  of  faintness,  and  with 


384 


DISEASES   OF   WOMEN. 


pain  in  defaecation.  She  was  admitted,  under  Dr.  Allen,  into  Stanmore 
Hospital,  complaining  of  pain,  especially  over  the  left  side.  There  was  a 
swelling  in  the  left  inguinal  and  hypogastric  regions,  and  still  some  hsemorrhagic 
discharge  from  the  uterus,  the  bowels  moving  with  diilculty.  There  was 
considerable  fuhiess  in  the  left  fornix.  The  os  uteri  was  patulous,  and 
there  was  sanious  discharge  from  it.  It  was  decided  to  dilate  the  uterus 
and  explore  the  cavity.  This  was  done  with  a  negative  result.  When 
she  was  a  fortnight  in  hospital  pain  and  distension  increased,  and  the 
temperature  range,  which  previously  had  been  nearly  normal,  varied  from 
100°  to  102°.  The  bowels  could  not  be  moved  by  enema.  On  the  seven- 
teenth day  from  her  admission  the  abdomen  was  opened.  A  large  sac, 
extending  above  the  umbilicus,  was  discovered.  To  the  anterior  surface  of 
this  the  bowel  was  adherent  in  parts,  and  also  the  omentum.  It  was  firmly 
fixed  posteriorly  and  quite  impossible  to  separate.  On  tapping,  the  sac  was 
found  to  contain  semi-coagulated  blood.  The  sac  wall  was,  therefore,  freelj'- 
opened  and  the  contents  turned  out.  The  edges  were  pared  and  the  sac  was 
stitched  by  interrupted  fishing-gut  sutures  all  round  to  the  peritoneum,  which 
was  then  brought  together  and  sutured,  leaving  sufficient  space  for  a  drainage- 
tube.  The  patient  made  an  miinterrupted  recovery.  The  contents  of  the  sac 
were  afterwards  carefully  examined  for  the  presence  of  a  mole,  but  such 
could  not  be  found.  No  tube  or  ovary  could  be  detected  on  the  left  side. 
There  had  evidently  been  recurrences  of  haemorrhage,  and  a  recent  bleeding 
within  the  few  days  prior  to  the  operation  explained  the  symptoms  from 
which  she  suffered  and  the  sudden  increase  in  the  size  of  the  swelling.* 

Rupture  of  Ovarian  and  Tubal  Cysts. — The  possibility  of  rupture  of  ovarian 
and  tubal  cysts  liappening  suddenly  has  to  be  remembered.  I  have  on  several 
occasions  removed  large-sized  blood-cysts  from  the  parovarium  and  tube. 
The  contents  of  such  cysts  cannot  be  diagnosed  save  by  operation,  or  aspira- 
tion through  the  vagina,  a  step  not  devoid  of  risk. 

la  all  other  cases  than  those  in  which  the  haemorrhage  is  the 
consequence  of  conception,  my  experience  of  pelvic  haemorrhage 
would  lead  me  not  to  interfere  hastily  with  any  collection  of  blood 


Fig.  259. — Paquelix's  Cautery  Scissors. 

or    coagulum.     The    aspirating-needle  may  be   used    both   for   the 

purpose  of  exploration  and  also  for  the  determination  and  evacuation 

of  pus.     Should  not  this  answer,  and  the   fluid  reaccumulate,  an 

*  Page  385.     See  Ectopic  Gestation. 


PELVIC  HJEMUlilillAaE.  "   3s5 


opening  should  be  made  with  the  gu<arded  bistoury,  Landau's 
branched  dilator  and  trocar  (Fig.  121),  or  the  thermo-cautery  (Fig. 
259),  and  the  cavity  subsequently  washed  out  with  some  weak  (777^77^) 
bi-chloride  of  mercury  or  formalin  (777777;;)  solution.  It  is  a  question  if 
this  latter  be  not  the  safest  method  of  puuction  of  a  purulent  intra- 
peritoneal collection  of  pus,  the  cavity  being  drained  subsequently 
and  tamponing  the  vagina  loosely  with  sterilized  iodoform  gauze. 

In  extra-peritoneal  h:>3matocele,  a  branch  steel  dilator  may  be 
employed  to  enlarge  the  vaginal  opening  and  admit  the  finger  and 
a  drainage  tube,  the  strictest  asepsis  being  maintained. 

Expectant  and  Radical  Treatment  of  Haematocele. 

There  is  a  valuable  communication  by  Paul  Zweifel,*  being  an  address  to 
the  Leipzig  Medical  Society,  given  in  June  of  the  same  year.  In  it  be  deals 
with  the  expectant  and  radical  treatment  of  hseniatocele.  He  strongly  advocates 
immediate  operation  in  recently  ruptured  tubal  gestation,  quoting  cases  in 
which  the  pulse  at  the  wrist  was  impercejjtible,  and  yet  the  operation  was 
followed  by  recovery.  In  internal  bleeding  he  says  '  the  indication  to  open 
the  abdomen  at  once,  arrest  the  hsemorrhage  and  remove  all  the  effused  blood, 
is,  of  course,  not  merely  valid  in  case  of  primary  rupture  or  erosion  of  the 
tube,  but  is  equally  stringent  in  secondary  btemorrhage.' 

He  urges  that  secondary  erosion  occurs  not  so  infrequently  as  Aschoff  and 
others  contend.  Rupture  of  the  encapsuled  hfematocelc  is  a  source  of  urgent 
danger.  He  thus  describes  posterior  colpotomy  for  hsematocele  :  It  '  consists  in 
opening,  layer  by  layer,  the  posterior  vaginal  vault  and  pouch  of  Douglas, 
evacuating  the  clotted  blooi  by  breaking  it  up  with  two  fingers,  washing  away 
any  remaining  clots,  and,  finally,  after  drying  it  out,  plugging  the  cavity  with 
iodoform  gauze.  This  operation  is  so  simple  that  it  may  be  performed  without 
aDicsthesia.  as  I  have  done  it  even  in  private  practice.  But  care  must  be  taken 
that  in  evacuating  the  blood  the  capsule  is  not  broken,  and  that  no  blood  masses 
are  left  round  the  ovum  in  the  tube,  for,  after  opening  from  below,  such  masses 
always  decompose,  and,  unless  the  drainage  is  absolutely  free,  the  decomposition 
leads  to  fever  and  sepsis. 

'  If  all  go  well,  posterior  colpotomy  is  without  danger,  and  in  a  fortnight  the 
patient  is  able  to  get  up.  Wiien  such  blood  masses  as  I  have  alluded  to  remain 
in  the  tube,  I  prefer,  for  sake  of  safety  and  uninterrupted  healing,  to  complete 
the  intervention  by  an  immediate  laparotomy,  and,  removing  all  the  blood  from 
above,  to  fill  the  sac  with  iodoform  gauze  and  shut  it  off  entirely  from  the 
peritoneal  cavity.' 

The  most  careful  investigation  of  107  cases  treated  in  the  Leipzig  klinik 
showed  that  57  per  cent,  of  those  treated  expectantly  recovered ;  in  forty  cases 
in  which  laparotomy  was  performed,  there  were  three  deaths,  but  these  three 
occurred  from  such  causes  as  purulent  peritonitis  and  tuberculosis,  profuse 
internal  hemorrhage,  and  the  rupture  of  a  suppurating  hjematocele.  On  the 
whole,  from  a  summary  of  211  cases  of  Zweifel's,  and  215  of  Thorn's,  in  which 
53  to  55  per  cent,  and  (55  per  cent,  relatively  were  treated  by  conservative 
measures,  Zweifel,  though,  as  he  says,  '  the  alleged  advocate  of  interference,' 
adopted  the  expectant  method  in  this  large  number  of  cases  of  hajmatocele. 

*  Brit.  Gyn.  Jour.,  Nov.,  1903. 

2   c 


CHAPTER   XIX. 


LACERATION    OF    THE    CERVIX. 


This  lesion,  varying  in  the  number  and  depth  of  rents  or  fissures  of 
the  cervix,  and  the  degree  of  pouting  of  the  cervical  canal,  is  the 
consequence  of  labour.  It  results  most  frequently  from  manual  or 
instrumental  interference,  and  too  early  rupture  of  the  membranes. 
In  short,  it  is  often,  though  by  no  means  necessarily,  the  fruit  of 
'  meddlesome  '  midwifery  and  hastily  conducted  labours.  In.  rapid 
labours,  in  which  delivery  is  precipitated,  such  rents  are  apt  to 
occur. 

The  rent  is  generally  transverse,  for,  as  Goodell  points  out,  the 
fissure-line,  when  lying  in  this  direction,  crosses  the  axis  of  motion 

of  the  uterus,  and  hence  the  tendency 
to  separation  of  the  flaps.  At  other 
times  the  fissures  are  multiple,  as  in 
this  drawing  after  Emmet. 

According  to  the  same  authority, 
laceration  is  most  frequent  on  the 
left  side,  this  being  attributed  to  the 
position  of  the  child's  head  in  the  right 
oblique  diameter,  the  occiput  lying 
anteriorly  to  the  left.  The  percent- 
age of  women  sufiering  from  uterine 
disease,  who  are  subject  to  laceration 
of  the  cervix,  has  been  variously  esti- 
mated at  from  ten  to  forty  per  cent.  (Schroeder,  Munde,  Ambrose, 
Pallen,  Barker,  Emmet,  Goodell). 

That  the  cervix  uteri  is  more  or  less  torn  in  a  large  proportion  of 
labours  all  will  admit.  Many  such  rents  close  spontaneously,  and 
a  considerable  number  cannot  be  said  to  cause  either  ill  consequences 
or  any  sufiei"ing  to  the  woman. 

Surgeons  must  not  take  up  any  extreme  view  of  the  necessity  for 
interference   in    every    case   of   lacerated    cex-vix.     Its   relation  to 


Fig.  260. 


-Bilateral  Lacera- 
tion. 


LACERATION   OF   THE   CEIiVTX. 


387 


.;^^ 


morbid  womb  conditions  is  now  generally  acknowledged,  and  we 
have  especially  to  thauk  American  gyniecologists  for  this,  as  for 
many  other  valuable  additions  to 
uterine  pathology.  We  have,  how- 
ever, to  avoid  being  influenced  in 
practice  by  an  exaggeration  of  the 
results  which  follow  from  a  lacera- 
tion. A  careful  examination  of  the 
uterus  will  enable  us  to  judge  of  the 
case  demanding  operative  interfer- 
ence, and  the  one  which  may  safely 
be  dealt  with  by  paUiative  measures, 
or  let  alone. 

Authorities  are  still  divided  as  to      Fig-   261. -Unilateral  Laceka- 

,,  ,.,.,.  ,  £   ,  TION   OF   THE    CeKVIX,   WITH    Ex- 

the  etiological  importance  01  lacera-  ...^  t?,,^^,.^..-     r\T. 

*  ^^  _  DCiMETEITIS    AND   iiiBOSION.       (_AU- 

tion   of    the    cervix,    in    regard    to         thor.) 

various    uterine    pathological     con-      Curettage,  chromic  acid  (grs.  ssx., 
ditions.  ad  5I),  laceration  closed,  nitric 

acid  applied  to  erosion. 
For  example,   Emil    Noeggerath    de- 
clares that  '  women  are  mor-e  likely  to  conceive  when  there  is  a  laceration 
than  when  there  is  not ;  the  position  of  the  uterus  is  not  affected  by  lacera- 
tion, its  axis  is  not  elongated  as  a  conserpience,  erosions  and  ulcerations  are 
not  more  frequentl}-  met  with  lacerations  than  without,  they  have  no  influence 
in  producing  uterine  disease,  eversion  of  the  lips  is  nevei-  the  direct  result  of 
a  laceration.'     Noeggerath  goes  so  far  as  to  assert  that  laceration  will  soon 
disappear  from  the  list  of  pathological  affections   of  the   uterus,  and  that 
operations  for  their  cure  will  be  things  of  the  past.     On  the  other  hand, 
^lunde  declares  that  cervical  lacerations  do  act  as  predisposing  factors  in  the 
production   of    uterine    disease,   the    fre- 
ipiencj^   and   severity   of    the   lesions   in- 
creasing directly  in  proportion  to  the  length 
and  depth  of  the  tear.     He  also  arrives  at 
the  conclusion  that  they  lessen  the  pro- 
ductive fertility  of  a  woman. 


I  believe  that  the  truth  lies  in  the 
mean  between  these  two  extremes  of 
opinion — certainly  rather  on  the  side 
of  the  view  generally  held  by  Ameri- 
can gynaecologists  on  the  importance 
of  lesion. 

It  is  my  belief  that  extensive  lacera- 
tions, followed  by  ectropion  of  the  cervical  lips,  follicular  degeneratiun. 


Fig.  262. — Stellate  Laceua- 

TIiiX. 


388  DISEASES   OF    WOMEN. 

and  erosions,  do  predispose  to  malignant  change  in  the  cervix.  As 
Skene  Keith  has  rightly  insisted,  the  scar  tissue  of  an  old  laceration 
is  responsible  for  much  of  the  trouble  that  follows  it. 

With  regard  to  recent  lacerations,  many  urge,  and  apparently 
with  reason,  that  the  sooner  the  rents  are  closed,  the  better,  the 
sutures  acting  also  as  a  hsemostatic.  It  is  asserted  that  the  lochial 
flow  does  not  prevent  primary  union,  but  any  such  operation  must 
be  conducted  with  every  possible  antiseptic  precaution.  Doderlin, 
Sanchez,  Toledo,  and  Strauss  have  shown  that  the  normal  lochial 
discharge,  when  taken  from  the  uterus,  is  devoid  of  germs,  but  that 
if  there  be  fever,  both  bacilli  and  cocci  are  found,  which  are  elimi- 
nated with  more  abundant  secretion  of  a  purulent  character.  The 
pathogenic  microbe  is  the  Streijtococcus.  Similar  germs  have  been 
found  by  Peraire  in  the  secretions  of  puerperal  metritis. 

I  could  instance  several  cases  of  women  restored  to  health  and 
procreative  capacity,  whose  lives  were  miserable  before  extensive 
lacerations  were  cured,  and  I  have  seen  several  cases  in  which 
I  believe  the  predisposing  cause  of  serious  uterine  disease  lay  in  old 
eversion  and  erosion,  the  consequence  of  an  unremedied  rent  in  the 
cervix. 

Diagnosis. — Though  in  the  majority  of  cases  there  is  not  any 
diflBculty  in  discovering  a  laceration  of  the  cervix  by  a  careful 
examination,  still  there  is  but  little  doubt  that  it  often  escapes 
detection.  This  is  more  apt  to  occur  when  there  is  a  considerable 
abrasion  of  the  cervix,  or  when  the  cylindrical  speculum  is  used. 
In  the  latter  case  we  may  press  the  lips  of  the  fissure  together,  and 
thus  close  the  torn  lips  of  the  mouth  of  the  womb. 

An  examination  for  a  laceration  of  the  cervix  should  be  made  in 
the  dorsal  position  or  in  this  manner  :  The  woman  is  placed  in  the 
semi-prone  position,  and  Sims'  speculum  is  applied  :  a  tenaculum  or 
hook  is  used,  and  the  two  lips  of  the  rent  are  drawn  forwards, 
when,  if  it  be  a  laceration,  the  raw  surface  disappears,  and  the 
characteristic  cleft  is  left. 

Consequences. — Erosion  and  ectropion  of  the  os  and  cervix  ; 
eversion  of  the  cervical  canal ;  monorrhagia  and  metrorrhagia ; 
subinvolution  ;  endometritis ;  parametritis  and  perimetritis  ;  adnexal 
disease  ;  cicatrization  of  the  cervix,  and  sterility.  There  is  little 
doubt  that  it  predisposes  to  eiDithelioma  and  malignant  disease  of 
the  cervix. 

Symptoms. — These  will  depend,  in  urgency  and  severity,  on  the 
extent  and  depth  of  the  laceration,  and  the  inveterate  character  or 


LACEMATTON  OF  THE  CERVIX.  389 

the  intensity  of  the  attendant  complications.  If  the  laceration  be 
chronic,  we  frequently  lincl  an  easily-bleeding  cervix,  menorrhagia, 
endocervical  discharge,  pain  in  walking,  loss  of  sexual  desire, 
neuralgia,  and  rellex  nervous  disturbances. 

Treatment. — It  is  either  palliative  or  operative.  The  palliative 
treatment  consists  in  rest,  warm  vaginal  douches  ;  local  depletion, 
attention  to  the  eroded  cervix  ;  glycerine,  ichthyol,  and  glycothymolin 
tampons ;  astringent  douches.  Also,  such  remedies  as  tampons  of 
borax  and  glycerine,  tannin  and  glycerine  ;  applications  of  cai'bolic 
acid  and  glycerine  with  iodine  or  ichthyol ;  chromic  acid  solution, 
and  the  other  means  spoken  of  for  the  treatment  of  menorrhagia, 
may  be  applied. 

John  Taylor*  instances  as  the  consequences  of  lacerations,  malpositions  of 
the  uterus,  interference  with  the  nutrition  of  the  cervix,  tendency  to  sepsis, 
endocervicitis  and  endometritis,  atrophy  of  the  uterine  wall,  sterility  and 
abortion.     Epithelioma  he  regards  as  only  a  very  rare  result. 

Operative  Measures. — Such  palliative  treatment  should  be  pursued 
in  order  that  the  uterus  may  be  brought  into  a  fit  state  for  operation, 
when  all  symptoms  of  metritis,  or  peri-utei'ine  inflammation,  have 
disappeared.  The  week  after  a  menstrual  period  is  chosen.  The 
instruments  required  are  a  vaginal  douche,  a  duck-bill  speculum  and 
a  few  vaginal  retractors,  two  vulsella,  a  long-handled  knife,  a 
curved  and  angular  scissors,  short  lance-headed  needles  of  Emmet  or 
Sims,  curved  needles,  needle-holder,  forceps,  silver  wire,  gut  or  silk, 
a  few  perineorrhaphy  hooks. 

Trachelorrhaphy  is  thus  performed.  The  patient  is  brought  well 
over  the  edge  of  the  operating  table  in  the  lithotomy  position. 
The  vagina  is  thoroughly  sterilized.  The  cervix  is  exposed,  drawn 
down  with  the  vulsellum,  and  kept  in  position  by  an  assistant. 
The  edges  of  the  laceration  are  first  brought  together  to  judge  how 
far  the  uterine  surfaces  have  to  be  denuded.  This  we  can  readily 
understand  when  we  recollect  the  compression  exerted  by  it  on 
the  cervical  nerves,  and  the  obliteration  of  the  glands  and  vessels. 

The  operator  begins  by  denuding  one  side  of  the  laceration,  and 
removing  the  tissue,  as  shown  in  the  drawing.  The  cicatricial 
tissue  in  the  angle  of  the  laceration  is  completely  removed.  The 
same  step  is  taken  on  the  other  side  if  the  laceration  be  bilateral. 
Each  lip  of  the  laceration  at  either  side  is  seized  in  a  vulsellum,  and 
both  are  brought  together  so  as  to  see  the  efifect  of  the  denudation. 

*  Brit.  Gyn.  Jour.,  Nov.,  1903. 


390 


DISEASES   OF    WOMEN. 


The  sutures  are  now  passed  and  the  rent  is  closed.  Chromicized 
cumol  gut  answers  the  purpose  well.  A  broad  strip  of  the  cervical 
surface  is  left  untouched,  to  form  a  future  cervical  canal. 

Fig.  263  shows  the  surface  denuded,  and  the  course  of  the  sutures, 

after  Emmet,  Fig.  264  ex- 
emplifies the  way  in  which 
the  sutures  lie  in  the  cervix 
before  they  are  tightened. 
Fig.  265  explains  the  closure 
of  the  cervix  and  the  tying 
of  the  sutures.  The  sutures 
are  passed  in  the  order  1, 
2,  3,  4.  One  side  is  first 
united  and  closed,  and  after- 
wards the  others.  The  en- 
tire operation  is  performed 
with  the  strictest  aseptic  precautions.  For  the  first  forty-eight  hours 
the  vagina  is  kept  tamjDoned  with  sterilized  iodoform  gauze.     After 


Fig.  263. — Emmet's  Operation — Denuded 
sokpace  and  sutuees. 


Fia  264. — Sutures  passed. 


Fig.  26.5. — Sutures  applied. 


this  it  is  douched  out  with  formalin  solution  (1  in  2000),  and  then 
a  loose  tampon  of  iodoform  gauze  or -moistened  chinosol  is  placed  in 
it.  This  is  repeated  daily.  It  is  better,  after  operating,  to  draw 
ofi"  the  patient's  urine,  but  from  the  third  day  she  may  pass  water 
herself,  leaning  forward  on  her  knees.  If  silver-wire  sutures  be 
used,  they  should  not  be  disturbed  for  ten  or  twelve  days.  The 
mistake  which  causes  many  failures  after  all  perineal,  utero-vaginal, 
and  vesico-vaginal  operations  is  too  early  interference  with  the 
sutures. 

There  is  just  one  caution  in  regard  to  the  closure  of  a  laceration 
which  it  is  well  to  give.  The  object  of  the  operation  is  to  restore 
the  cervix  uteri  to  its  normal  condition,  and  the  os  uteri  to  the  shape 
and  size  it  would   naturally  present  afterwards  in  the  multipara 


LACERATION  OF   THE   CERVIX.  391 

under  ordinary  conditions.  It  is  not  right  to  so  close  the  cervical 
canal  that  conception  or  labour  are  interfered  with.  In  short,  not, 
as  a  patient  once  remarked,  to  have  the  uterus  so  stitched  that  it 
had  to  be  "unstitched"  and  "restitched"  for  the  undoing  of  the 
former  stitching. 

Examination  at  and  after  Childbed. — Many  Continental  and 
American  authorities  have  urged  that  after  all  labours  the  uterus 
should  be  examined  at  least  before  the  end  of  the  puerperal  month, 
when  the  patient  frequently  passes  from  under  the  care  of  the 
practitioner.  This  doubtless  would  be  an  admirable  rule  to  follow 
whenever  feasible.  Unfortunately  attention  at  the  time  of 
delivery  is  generally  concentrated  on  the  preservation  of  the 
perineum,  and  any  injury  which  may  happen  to  it.  In  instrumental 
delivery,  especially  where  there  is  difficulty  in  the  delivery  of  the 
head,  or  when  version  is  performed,  the  cervix  suffers  as  well  as 
the  perineum,  and  we  know  that  severe  postpartum  haemorrhage  is 
frequently  caused  by  deep  lacerations  of  the  cervix  as  well  as  those 
of  the  perineum.  Therefore,  in  instrumental  delivery,  and  when 
there  is  haemorrhage  after  the  placenta  is  delivered,  an  examination 
of  the  cervix  ought  to  be  made,  and  any  rent  should  be  immediately 
closed  with  aseptic  gut.  This  will  not  only  arrest  the  present 
bleeding,  but  also  anticipate  one  of  the  causes  of  "secondary 
haemorrhage"  (McClintock)  and  subinvolution  of  the  uterus,  which 
undoubtedly  are  occasionally  due  to  cervical  lacerations.  No 
patient  should  pass  out  of  the  obstetrician's  hands  after  parturition 
hefore  he  has  ascertained  that  the  integrity  of  the  cervix  has  not  heen 
seriously  interfered  with. 


CHAPTER  XX. 

UTERINE    NEOPLASMS— POLYPUS   UTERI. 

Though  polypi  are  properly  included  in  the  description  of  uterine 
neoplasms,  a  uterine  polypus  is  a  sufficiently  characteristic  growth 
to  warrant,  for  clinical  purposes,  a  distinct  study. 

Polypi  we  may  classify  according  to  the  elementary  tissues  from 
which  they  take  their  origin — cellular,  glandular,  fibrous,  placental. 


Fig.  266. — SrsMucors 
Fibroid. 


Fig.  268. — Octlixe  Diagram  of 
Polypus  with  Loxg  Pedicle 
attached    to   the   snmmit   of 

■  THE  Uterixe  Cavity  :  the 
Ceevical  Caxal  coxteacted  on 
Pedicle. 


Fig.  267.— Ol't- 
lixe  Diagram 
OF  Polypus 
of  Cekvix. 
(Adapted 
fromThomas.)- 

This  may  lead  to  partial  mversion. 

The  first  variety,  springing  from  the  cervix,  consists  principally 
of  cellular  tissue  and  mucous  membrane ;  the  second  (also  arising 
from  the  cervix)  of  hypertrophied  follicles  and  connective  tissue  ; 
the  third  of  muscular  and  connective-tissue  elements,  the  former 
preponderating.  Placental  polypi  have  their  origin  in  portions  of 
placenta  that  have  been  left  in  utero,  and  which,  becoming  organized 
and  incorporated  with  the  uterus,  form  polypi. 


PLATE   XXVII. 


Placextal  Polypus.    (BrMJi.) 

Prep,  in  Frauenklinik  in  Basil.  A,  B,  utero-placental  arteries ;  C,  E,  internal  and 
external  os ;  D,  polypus  projecting  from  uterus ;  F,  placental  attachment 
witli  blood  coagula. 

[To  face  p.  392. 


UTEH  [NE   XEOPLA  SiM  S—  P  0  L  YP  US    UTERI. 


393 


Fibroid  polypi  spring  from  the  body  of  the  uterus,  and  are  at 
one  period  of  their  growth  submucous  fibroids.  They  assume  the 
form  of  the  polypi  through  extrusion  into  the  uterine  cavity,  and  by 
gradual  narrowing  of  the  base  of  attachment  into  a  pedicle.* 

Diagnosis. — This  will  depend  on  the  size  and  position  of  the 
polypus.  Whenever  obscure  monorrhagia  or  metrorrhagia  occurs  and 
persists,  especially  if  the 


discharge  continue  foul 
and  offensive,  there  is 
but  one  safe  rule,  which 
is  to  dilate  and  explore 
the  uterus.  The  presence 
of  a  polypus  can  be  then 
determined  (see  p.  89). 

Dysmenorrhoea  and 
Menorrhagia. — It  must 
be  remembered  that  a 
small  polypus  may  be 
concealed  in  utero  and 
cause  severe  dysmenor- 
rhoea without  the  occur- 
rence of  monorrhagia  or 
any  perceptible  uterine 
enlargement. 

We  may  be  further  led 
to  suspect  that  a  polypus 
is  present  if  there  be 
some  enlargement  of  the 
fundus,  and  the  cervical 
canal  is  more  patulous 
than  in  the  normal  con- 
dition. 

Importance  of  Full  Dilatation. — The  first  step  towards  the 
diagnosis  and  treatment  of  polypus  is  free  dilatation  of  the  cervix. 
The  facility  with  which  we  can  feel  the  growth  will  depend  on  its 
size  and  position.  At  times  this  is  comparatively  easy  ;  occasionally 
it  is  very  difficult.  An  extra-uterine  polypus  is,  of  course,  felt 
at  once  with  the  finger.  The  principal  danger  is  that  we  may 
confound  a  large  growth  with  inversion  of  the  uterus.  We  are  not 
likely  to  mistake  it  for  prolapse. 

*  See  pp.  400,  405.  f  See  chapter  on  Follicular  Degeneration. 


Fig.  269. — Fibeoid  Tumour  of  the  Uterus, 
SHOWING  Encapsulation  in  the  Uterine  Pa- 
renchyma, AND  the  Attendant  Develop- 
ment OP  Cystic  Polypi  in  the  Cervix.  (St. 
Thomas's  Hospital,  Eobert  Barnes.!) 

Two-tMrds  natural  size. 


394  DISEASES   OF    WOMEN. 

A  curious  case,  showing  how  one  may  be  mistaken  if  the  uterus 
be  not  dilated,  occurred  to  the  author  : — 

Retrocession  of  a  Polypus. — A  lady,  in  whom  pregnancy  was  diagnosed, 
consulted  me  to  verify  the  opinion.  On  examination,  I  was  sm'prised  to  find 
a  bleeding  fibroid  polypus  protruding  from  the  uterus.  I  advised  its  removal. 
She  had  severe  hgemorrhage  the  next  few  daj's,  and  oxDeration  had  to  be  un- 
avoidably postponed.  When  placed  under  ether,  which  she  insisted  on 
having,  to  my  surprise  there  was  no  polypus  visible.  I  passed  a  uterine 
sound  into  the  cavity,  and  as  far  as  I  could  judge  it  moved  freely  in  utero. 
I  could  discover  no  growth.  I  came  to  the  conclusion  that  the  polypus  had 
become  detached  during  the  baamorrhage  of  the  preceding  days.  A  week 
subsequently  there  was  a  return  of  bleeding  and  some  watery  discharge.  On 
examination,  I  again  saw  the  i^olypns  appearing  at  the  os  uteri.  I  removed 
it  on  the  following  day,  and  found  the  pedicle  attached  to  the  fundus.  It 
would  appear  that  on  the  previous  occasions,  under  the  influence  of  ether,  the 
growth  had  returned  into  the  cavity  of  the  uterus  and  so  passed  out  of  sight. 

Recurrent  Intra-uterine  Fibroid  as  an  Undetected  Source  of  Dysmenorrlioea  and 
Metrorrhagia. — In  February,  1895,  I  exhibited  an  intra-uterine  polypus  at  the 
Gynascological  Society,  removed  from  a  patient  aged  32,  recently  married,  in 
whom  the  loss  of  blood  and  aggi'avated  dysmenorrlioea  had  brought  about  a 
most  serious  ansemic  condition.  Not  long  before  I  saw  her,  and  previous  to 
her  marriage,  the  uterus  bad  been  dilated  and  curetted  by  a  distinguished 
obstetrician.  The  submucous  tumour  was  the  size  of  a  small  pear.  I  dis- 
covered the  intra-uterine  growth  when  proceeding  to  divide  the  cervix  (under 
an  ansesthetic),  as  from  the  recent  curettage  I  did  not  suspect  its  presence. 
The  adnexa  were  healthy.  Evidently  the  curette  had  passed  round  the  gi'owth, 
and  the  imperfect  dilatation  had- not  revealed  it.  The  case  was  one  showing 
the  value  of  ansesthesia  in  diagnosis,  and  the  importance  of  sufficient  dilatation 
and  exploration  in  dysmenorrhcea  and  metrorrhagia.  On  two  subsequent 
occasions,  at  intervals  of  some  twelve  months,  I  removed  large  intra-uterine 
polypi  from  the  uterus  of  this  patient.  She  is  now  a  robust  woman,  and  has 
three  children. 

The  following  case  needs  no  comment  to  show  the  necessity  for 
great  care  in  the  diagnosis  of  intra-uterine  growths  : — 

Salpingo-odphorectomy  performed  for  Haemorrhage — Actual  Cause 
discovered  to  be  Polypus. 

Fancourt  Barnes  recorded  a  case  in  which  the  appendages  were  removed 
on  account  of  excessive  metrorrhagia.  The  loss  of  blood  had  been  so  severe 
and  reiterated  that  the  patient  was  rendered  extremely  anaemic,  pulseless,  and 
almost  moribund.  Intra-uterine  medication  had  afforded  some  rebef  for  a 
time,  but  the  haemorrhage  had  returned  and  ignipuncture  was  tried  with  a 
like  result.  The  left  ovary  was  cystic  and  adherent,  but  the  right  was  free. 
For  some  months  afterwards  there  was  no  bleeding,  but  again  the  haemorrhage 
recurred.     Lawson  Tait  saw  her,  and  advised  curettage.     The  uterus  was 


UTERINE   NEOPLASMS— POLYPUS    UTERL  3{)5 

dilated  for  this  purpose,  with  the  result  of  revealing  the  presence  of  a  small 
sessile  fibroid  growth,  which  was  removed  with  the  scissors. 

There  is  a  complication  which  has  to  be  kept  in  mind,  A  patient, 
a  multipara,  is  sufTering  at  the  menopause  from  metrorrhagia.  The 
uterus  is  enlarged,  the  cervix  soft  and  follicular  ;  there  is  some 
discharge  from  the  canal.  We  dilate  the  uterus,  and  discover  a 
small  polypus — possibly  two.  These  we  remove.  Still  the  metror- 
rhagia continues.  There  has  been  chronic  hyperplasia,  and  endo- 
metritis antecedent  to  and  attendant  upon  the  growth  of  the 
polypus.  It  is  in  these  cases  that  curettage,  or  the  appKcation 
of  nitric  acid,  should  follow  the  removal  of  the  polypus.  This  is 
the  classical  case  in  which  atmocmisis  would  be  indicated  after 
curettage. 


Clinical  Evidences  of  the  Presence  of  a  Polypus. 

We  may  thus  tabulate  the  positive  and  negative  signs  of  uterine 
polypus  : — 

Positive. — A  tumour  which  has  slowly  increased  in  size,  pyriform 
in  shape,  having  a  narrow  neck  or  pedicle,  insensible  to  touch,  not 
painful  when  punctured,  and  varying  in  size. 

Haemorrhage  is  a  constant  accompaniment  of  polypus,  and  there 
may  be  a  foul  sanious  discharge. 

If  the  tumour  be  in  utero,  the  sound  passes  into  the  uterus  from 
two  and  a  half  inches  upwards,  the  cavity  of  the  uterus  being 
enlarged  to  accommodate  the  growth  ;  if  in  the  vagina,  we  can 
trace  the  pedicle  of  the  polypus  to  the  cervix,  and  the  uterine 
sound  passes  above  this,  inside  the  cervix,  for  over  two  and  a  half 
inches.  The  encircling  ring  of  the  cervix  is  traced  below  or  around 
the  pedicle,  and  the  uterine  sound  can  be  passed  inside  the  cervix, 
between  the  wall  of  the  uterus  and  the  tumour. 

By  careful  conjoined  examination  the  fundus  can  be  felt  in 
position,  and  has  no  marked  depression.  Thus  the  size  and  con- 
sistency of  a  polypus  may  be  estimated  :  it  may  occur  in  nulliparous 
women  and  virgins. 

Important  Negative  Signs. — Absence  of  the  os  uteri ;  absence  of 
sensitiveness,  and  commonly  freedom  from  pain. 

Symtomatology. — The  principal  symptoms  are:  Haemorrhage, 
uterine  pain,  vesical  and  rectal  distress  (dependent  upon  the  size 
of  the  polypus   and  its  position)  ;  dragging  pain  in  the  back,  and 


396 


DISEASES   OF    WOMEN. 


perhaps  difficulty  in  walking  if  the  polypus  be  large  ;  occasionally, 
dysmenorrhcea. 

Removal. — We  remove  a  polypus  by  means  of  the  ecraseur,  the 
galvanic  cautery  wire,  the  polyptome,  or  by  hysterectomy.  Small 
polypi  may  easily  be  twisted  off. 

If  the  growth  be  intra-uterine,  the  uterus  should  be  thoroughly 
dilated.  An  anaesthetic  is  as  a  rule  not  necessary.  The  removal  is 
not  sufficiently  painful  or  distressing  to  require  it.  In  the  instance 
of  some  very  large  polypi  in  nulliparous  women  and  virgins,  it  is 
well,  for  a  few  days  previous  to  operating,  to  distend  the  vagina 


Fig.  270. — Fibroid  Poltpcs  'which  has  been  exteuded  from  the  Uterine 
Cavity  and  retains  its  Shape.     (College  of  Surgeons,  Kobert  Barnes.) 

HaK-size. 

with  a  Barnes's  larger-sized  hydrostatic  bag.  The  woman  is  given 
a  dose  of  bromide  of  potassium  the  night  before  the  operation.  She 
is  placed  in  the  lithotomy  position  on  a  suitable  couch  or  table,  and 
by  means  of  the  fingers  or  a  notched  director  the  wire  is  carried  well 
up  to  the  pedicle  of  the  tumour ;  after  which  manceuvre,  the 
ecraseur  having  been  pushed  as  far  as  the  neck  of  the  polypus,  the 
wire  is  gradually  tightened.  It  can  be  now  adjusted  to  the  pedicle, 
as  near  as  possible  to  the  uterine  wall,  without  injury  to  the  latter. 
The  tumour  is  then  removed  by  slowly  tightening  the  wire  and 
resting  at  intervals  in  the  usual  manner. 

Any  complaint  of  pain  is  an  indication  of  injury  to  the  uterus. 


UTERINE  NEOPLASMS— POLYPUS    UTERI. 


397 


When  severed,  and  loose  in  the  vagina,  the  tumour  may  be 
removed  by  an  ovum  forceps.  If  the  polypus  be  very  lai-ge,  and 
cannot  after  its  detachment 
be  brought  away,  or  if  it  en- 
danger the  perineum  and  its 
vessels,  it  must  be  divided 
with  a  polyptome.  Sir  J.  Y. 
Simpson  devised  a  cutting- 
hook  for  the  purpose  (Simp- 
son's  polyptome).  The  peri- 
neum has  been  incised  at 
either  side  of  the  median  line, 
in  order  to  enlarge  the  outlet, 
so  as  to  facilitate  the  removal 
of  a  large  polypus. 

Some  years  ago  I  removed  from 
the  uterus  of  a  nullipara  a  polypus 
larger  than  an  average  size  fcetal 
skull,  and  experienced  consider- 
able difficulty  in  its  extraction  from 
the  vagina.  This  I  effected  by 
lateral  incisions  of  the  perineum. 
I  then  felt  the  want  of  some  in- 
strument (which  would  combine 
the  purpose  of  forceps  and  cutting-knife)  for  the  safe  removal  of  these 
large  growths  without  the  necessity  of  incising  the  perineum,  or  the  risk 
of  laceratbg  it.  The  application  of  the  ecraseur  to  divide  the  tumour 
into  segments  is  tedious,  and  at  times  difficult.  To  meet  such  difficulties 
I  devised  an  instrument  consisting  of  a  straight  forceps,  lightly  made  with 
slender  blades,  yet  sufficiently  strong  to  compress  the  tumour.     A  gi'oove 


Fig.  271. 


-Application  of  Ec 
Polypus. 


Fig.  272. — Wire  Conductoks. 

is  cut  in  the  lower  fourth  of  these  blades,  and  they  are  so  shaped  inside  that 
the  edge  of  a  movable  knife  or  saw  glides  easily  along  the  blade.  They  lock 
readily  on  a  revolving  pivot,  and  the  same  lock  canies  a  short  sheath,  through 
which  the  knife  passes.  The  handle  of  the  forceps  is  at  right  angles  to  the 
shank,  and  each  half  is  connected  by  a  rack  and  pinion-bar.  A  cutting  blade 
accompanies  the  forceps,  shaped  somewhat  like  a  dagger,  so  as  to  readily  pierce 
anv  tumour,  and  cut  from  the  centre  outwards :  a  second  is  a  fine  saw.    These 


398 


DISEASES   OF   WOMEN. 


are  made  of  the  finest  tempered  steel.  The  tumour  can  thus  be  gi-asped  and 
cut  through  the  centre.  The  blades  are  either  turned  round  in  the  vagina,  or 
the  forceps  may  be  applied  in  a  different  direction,  and  the  mass  cut  in  four 
or  more  pieces.     These  segments  may  be  separately  withdrawn.     It  is  im- 


FiG.  273. — Author's  Polyptome. 

possible  to  divide  across,  even  with  such  an  instrument,  a  large  and  possibly 
calcified  fibroid.  It  is  better  to  apply  the  forceps,  and,  if  there  be  a  risk  of 
laceration  of  the  perineum,  to  make  two  divergent  cuts  at  each  side  of  the 
fourchette  so  as  to  enlarge  the  vulvar  orifice.  These  are  closed  after  removal. 
The  usual  antiseptic  precautions  are  taken  both  before  and  after  removal. 


Large  Polypus  adherent  to  the  Vagina. 

I  showed  at  the  Gynsecological  Society  a  large  fibroid  poljqius  covered  with 
rough  adhesions.  It  completely  filled  the  vagina,  and  w^as  quite  as  large  as  a 
foetal  skull.  On  passing  my  fingers  into  the  vagina,  I  was  sin-prised  to  find 
the  tumour  quite  adherent  to  the  vaginal  wall.  The  breaking  down  of  the 
adhesions  was  attended  by  the  most  profuse  haemorrhage,  which  ceased  when 
the  tumour  was  detached.  I  had  considerable  difficulty  in  getting  the  rope 
wire  above  the  mass.  In  this  case,  by  drawing  the  perineum  well  back  with 
the  Sims  speculum  and  using  a  large  vulsellum  for  delivery,  the  polypus  was 
removed  without  injury  to  the  perineum. 

Hysterotomy. — Clarence  Webster  *  quotes  a  case  of  Veit's,  in  which,  after 
dilatation  of  the  cervix,  he  was  unable  to  remove  a  polypus.  In  order  to  get 
more  access  to  it,  he  cut  through  the  attachment  of  the  vagina  to  the  anterior 
wall  of  the  cervix  by  means  of  a  transverse  incision,  and  then  separated  the 
bladder  almost  as  far  up  as  the  isthmus.  "  He  next  divided  the  anterior  wall 
of  the  uterus  by  a  median  incision  as  far  up  as  this  jjoint,  and  w^as  thereafter 
easily  able  to  remove  the  polypus.  The  incision  was  again  closed,  and  the 
vagina  united  to  the  cervix. 

*  Brit.  Gyn.  Jour.,  Feb.,  1895. 


CHAPTER    XXI. 

UTERINE    NEOPLASMS  (continued). 
MYOMA. 

Etiolog'ical  and  Pathological. 

Etiology  and  Pathology. — Uterine  fibroids  occur  frequently  in  women 
otherwise  perfectly  healthy,  and  often  appear  when  no  predisposing 
or  exciting  cause  can  be  traced.  The  period  of  life  has  much  to 
say  to  their  occurrence.  We  understand  this  relationship  if  we 
remember  the  active  influence  of  ovulation  and  pregnancy  on  the 
uterine  tissue.  They  are  found  most  frequently  from  the  ages  of 
thirty  to  fifty,  and  in  married  women.  Still,  they  are  often  met 
with  in  the  unmarried,  and  in  women  under  thirty.  There  is  a 
relationship  also  between  uterine  fibroids  and  sterility.  Both  are 
constantly  associated  with  an  old  history  of  dysmenorrhcea.  It  is 
curious  that  the  African  races,  in  which  malignant  disease  is  not 
a  common  aflfection,  should  be  so  liable  to  fibroid  tumours. 

Fibroid  growths  of  the  uterus  have  their  origin  in  the  muscular 
and  connective  tissues  in  the  wall  of  the  uterus,  and  more  especially 
those  of  the  body.  In  this  pathological  departure  from  the  normal 
matological  relations  of  the  tissues  in  the  uterine  pai'ietes  the  vessels 
appear  to  play  an  important  part.  The  name  '  fibro-myoma ' 
expresses  the  constitution  of  the  tumour  most  frequently  found. 
The  term  "  myoma "  is  now  more  generally  employed  to  embrace 
those  growths  pre^'ious]y  known  as  "  fibroid  "  and  "  fibro-myoma." 
Some  tumours  present  more  the  character  of  the  muscular, 
others  of  the  connective-tissue  elements.  The  tumour  is  pro- 
portionally hard,  according  to  its  age  and  the  development  or 
preponderance  of  the  fibrous  tissue. 

With  regard  to  the  vascularity  of  fibroids,  save  in  the  very  large 
varieties,  the  arteries  are  not  numerous.  Yet  the  fact  that  the 
bruit  de  souffle  is  occasionally  heard  shows  the  size  which  may  be 
attained  by  the  vessel.     The  veins,  especially  those  of  the  periphery, 


400 


DISEASES   OF    WOMEN. 


are  large.  A  condition  of  venous  intussusception,  with  fibromatous 
fibres  interlacing,  has  been  termed  by  Yirchow  '  telangiectasis,'  or 
cavernous  myoma.  Fibromatous  polypi  are  not  vascular,  and  the 
pedicle  seldom  contains  vessels  of  any  size,  while  those  which  are 
present  are  remarkable  for  their  retractile  quality.  Klebs  has 
described  lymphatic  spaces  between  the  bundles  of  fibres.  Nerves 
have  been  traced  into  them  by  Bidder  and  Herz. 

Alban  Doran  says  :  '  The  muscle-cells  of  a  myoma  are  usually  larger  than 
those  of  the  uterus  in  which  it  grows.  Hence  in  a  myoma  removed  during 
pregnancy  they  appear  very  large.  Fig.  274  represents  a  section  of  a  myoma- 
tous tumour  of  the  uterus,  removed  at  about  the  fourth  month  of  pregnane}'. 


if, 

Wll  *    ' 


limm 


$ 

i 


Fig.    274.— Myoma  of  a  Pkeg-  Fig.  275.— Fibromyoma  of  the 

NANT    Uterus,    showing    Ex-  Uterus. 

TREME  Hypertrophy  of    the  j^^  ^^^^  ^^  ^^^  g^j^  ^^^ 

Muscle-cells.      (Alban    Do-  muscle -cells  and    the   fibrous 

'  '^  tissue   lie   separate;    in   others 

they  are  closely  blended. 

'  By  the  term  fibro-myoma  is  implied  a  uterine  tumour  where  groups  of 
muscle-cells  are  blended  with,  or  completely  separated  by,  conspicuous  tracts 
of  true  fibrous  tissue.  A  small  amount  of  young  connective  tissue  as  seen  in 
the  uterus  is  never  absent  from  a  pure  myoma ;  in  fibro-myoma  we  see  well- 
defined  wavy  bands  of  white  fibre.  Microscopically  no  two  sections  of  fibro- 
myoma  of  the  uterus  look  alike.  Sometimes  wide  bands,  purely  made  up  of 
muscle-cells,  predominate ;  sometimes  the  field  is  covered  with  white  fibre, 
resembling  that  of  which  a  fibroma  of  the  ovary  (Figs.  274-276)  is  entirely 
composed.  Lastly,  the  muscle-cells,  or  at  least  structures  resembling  them 
in  size  and  appearance,  may  be  intimately  connected  with  the  fibrils  which 
make  up  the  fibrous  bands.  This  latter  condition  is  well  indicated  in  Figs. 
274,  275,  which  represent  a  section  of  a  pedunculated  subperitoneal  "  fibroid." 


UTERIXE  NEOPLASMS— M  VOMA. 


401 


Of  all  "  fibroids,"  fibro-niyoma  is  the  commonest  form.  The  presence  of 
connective  tissue  in  myoma,  and  also  in  fibro-myoma,  probably  accoimts  for 
the  malignant  degeneration 
of  "  fibroids,"  of  which  cases 
have  been  recorded.' 


M 


Mode  of  Origin  of 
Myoma  and  its  De- 
velopment. 


V; 


w 


Fig.  276.- 


-."^ECTION    OF    FiBI;' 

Utebus. 


OIT'LMAToUS 


In  an  interesting  historical 
summary  of  the  develop- 
ment of  the  pathology  of 
fibromyomatous  tumours,  as 
also  in  his  work  on  •  Uterine 
Tumoui-s.'  Roger  Williams  * 
arrives  at  the  conclusion  that 
there  are  '  good  reasons  for 
belie^^ng  that  most  uterine 
myomata  arise  from  dislo- 
cated myomatous  elements 
connected  with  abnormally 
evolving  "  nests  "  of  "Wolffian  and  Miillerian  structui-es.  Thus  their  initial 
multiplicity  may  be  accounted  for.'  There  must  also  be  a  certain  amount 
of  truth  in  BroussaLs'  doctrine  of  '  organic  irritation  and  chronic  inflammation,' 
which  Virchow  indorsed,  giving  the  name  of  myomata  to  those  fibroid 
tumours  containing  muscle-cells  similar  to  those  of  the  uterine  wall. 

Gottschalk.  Keifer,  Roesger,  and  Tridondani,  also  associate  the  origin  of 
myomata  with  changes  in  the  vessels  of  the  uterus  in  their  tortuosity,  in  the 
arrangement  of  the  muscle  fibres  about  the  vessels,  and  in  the  enlarged  mus- 
cular coats,  in  which  muscular  development  the  tumour  is  supposed  to  take  its 
origin.  Santi,  however,  believes  that  they  arise  from  the  uterine  muscle  fibres. 
The  circular  arrangement  of  the  muscle  fibres  round  the  vessels  does  not 
accord  with  the  longitudinal  direction  of  the  growth  of  the  fibres  of  the  myoma. 

'  Stanmore  Bishop  t  has  studied  the  vascular  changes  in  myomata,  and  the 
effect  of  such  changes  on  their  development.  He  examined  certain  uteri  from 
which  fibroid  growths  had  previously  been  removed  ;  these  uteri  having  been 
later  excised  for  carcinoma  of  the  cervix,  he  had  sections  made  in  order  to 
see  whether  any  vessels  could  be  found  in  a  later  stage  than  those  referred  to 
above,  in  which  the  process  of  the  formation  of  fibroid  tumours  might  be  studied. 

'  Cambernon,  in  1844,  suggested  that  an  unfertilized  ovum  had  found  its 
way  into  the  uterine  tissue,  and  had  been  arrested  in  its  passage.  But  this  was 
only  theory.     Others,  who  depended  more  upon  actual  examination,  found 

*  '  The  Pathology  and  Surgical  Treatment  of  Uterine  Tumours  in  the  Nine- 
teenth Century,"  Brit.  Gyn.  Jour.,  1901. 

t  Stanmore  Bishop  on  'Changes  in  Fibromatous  Uteri,'  Brit.  Gyn.  Jour., 
Feb..  1902. 

2  P 


402 


DISEASES    OF    WOMEN. 


epithelial  relics,  whicli  Eicker  believed  were  the  remains  of  the  primitive 
epithelium  of  Miiller's  duct.    Max  Voigt  found  glandular  structures  in  certain 

myomata.  Hanser  and 
Diesterweg  traced  these 
to  Miiller's  duct ;  Nagel 
and  Brens  to  the  Wolf- 
fian duct.  Meyer 
showed  glandular  struc- 
tures in  the  muscular 
uterine  tissue  of  new- 
born children,  and  also 
in  that  of  adults.  He 
also  showed  sections  of 
adenoma  clearly  de- 
rived from  the  Wolffian 
duct.  Klein  demon- 
strated the  remains  of 
the  same  duct  in  the 
uterus  of  a  new-born 
child. 

'Although  some 
growths  may  be  found 
in  which  adenomatous 
tissue  is  present,  the 
development  of  which 
raaj^  be  explained  in 
this  way,  such  an  ex- 
planation would  not 
cover  the  great  ma- 
jority of  fibroid  growths 
which  contain  no  such 
structures ;  and  these 
have  been  variously 
interpreted.  Thus,  Vir- 
chow  believed  them  to 
represent  simply  lo- 
calized hyperplasia  of 
previously  existing 
muscular  fibres ;  Lenn, 
the  results  of  the  de- 
velopment of  a  matrix 
of  myoblasts,  existing 
independently  of  pre- 
exislingmuscular  fibres. 
Mary  D.  Jones  con- 
sidered that  their  start- 
ing-point was  in  in- 
flammatory products ;  and  Galippe  and  Laudouzy  described  certain  spherical 
cocci  which  initiated  these  inflammatory  changes. 


No.  II.,  corpuscular  formation. 


No.  III.,  glands  of  the  cervix  and  commencing 
suppuration. 

Fig.  277. — Showing  Degenerative  Changes  in  the 
Muscle  Fibres  op  a  Myoma.  (From  Sections  by 
Mary  Dixon  Jones.) 


PLATE   XX\  in. 


A.. 


GlAXT    MULTIPLE    JNIXOMA.       (AUTHOR.) 

Keduced  to  less  than  half-size.  Dotted  line  A,  A,  marks  the  upper  border  of  tlje 
abdominal  portion.  The  mass  above  the  line  pushed  up  the  diaphragm  at 
the  left  side,  causing  dyspncea  and  tachycardia.  This  was  not  discerned 
until  operation.  The  lower  mass  filled  tlie  abdomen.  Eemoved  by  supra- 
vaginal hysterectomy.  [To  face  p.  i02. 


PLATE   XXIX. 


Posterior  Surface  of  same  TniouR.    (Al-thor.) 

ITo  face  p.  i05. 


Fig.  277a. — Showing  Early  .Stagks  uf  Hypektrophy  of  the  Arterial 
Median  Coat.    (Stanmore  Bishop.) 


111 


Fig.  277b. — Considerable  Hypertrophy  of  Muscular  Layer. 

(Stanmore  Bishop.) 

On  the  left,  a  mass  of  fibres  are  seen  running  longitudinally  in  the  axis  of  the 

arterial  lumen,  within  the  circular  fibres,  but  outside  the  intima. 

[To  face  p.  402. 


.1            \> 

Fig.  277c. — Group  of  Arteeies  showing  Various  Stages  of  Hypertrophy  of  Muscular 
Layer.    (Stakmore  Bishop.)  [To  face  p.  4:03. 


UTERIXE  NEOPLASM,^— MYOMA.  403 


*  Without  hazarding  any  opinion  as  to  the  ultimate  cause  of  fibroid  growths, 
several  writers  iiave  contented  themselves  with  careful  description  of  the 
appearances  found  in  them,  and  this  is  at  present  the  safest  position.  Espe- 
cially has  this  been  interesting  in  the  case  of  the  arterial  supply  of  them, 
Roesger  says  that,  as  in  the  foetal  uterus,  the  arteries  affect  the  direction  of 
the  muscles,  so  it  is  in  the  case  of  the  smallest  myomata. 

'  Klein wacli tor  described  in  the  smallest  myomata  small  bloodvessels  just 
above  the  size  of  capillaries;  these  were  surrounded  by  round  cells,  which 
change  into  spindle  cells,  finally  resembling  perfect  organic  bands  of  muscle 
fibre.  Coster  also  described  embryonic  cells  in  the  adventitia  of  similar 
vessels  which  developed  into  smooth  muscular  fibres.  Pilliet,  Klebs,  Meslay, 
and  Hyenne  also  describe  this  change.  Pilliet  says  the  endothelium  of  these 
arterioles  remains  normal :  the  adventitia  gives  origin  to  a  zone  of  embryonic 
cells  which  multiply  and  develop  into  rows  of  concentrically  placed  smooth 
muscular  fibres  arranged  around  the  vessel ;  the  fibrous  layers  arise  from  the 
transformation  of  the  most  peripheral  muscular  layers  which  are  furthest  from 
the  vessel,  and  are  therefore  furthest  from  the  blood  channel,  Kleinwachter 
described  these  changes  as  occurring  in  the  smallest  arteries,  Roesger  in  those 
possessing  an  adventitia,  Gottschalk  in  the  larger  vessels.  Miiller  disputes 
these  observations. 

'  The  Figs.  (Figs.  277a,  277n,  and  277c)  show  the  changes  in  the  muscular 
walls  of  the  vessels,  in  which  the  hypertrophy  advances  so  far  as  to  obliterate 
the  lumen,  producing  also  irregular  thickening  and  tortuosity  of  the  arteries, 
these  dra^vings  being  taken  from  the  muscular  tissue  of  the  uterus  itself,  and 
not  from  the  neoplasm.' 

Mary  Dixon  Jones  regards  the  formation  of  a  fibroid  tumour  as  a  consequence 
of  granular  and  medullary  change  in  the  uterine  tissue,  this  change  com- 
mencing in  the  utei'ine  fibres,  and  being  consequent  upon  and  associated  with 
an  inflammator}'  process  and  the  development  of  corpuscles  with  granules. 
There  is  ultimate  destruction  of  the  muscle  fibre,  and  a  new  formation. 

Mode  and  Rapidity  of  Growth  of  Pibromyomata. 

Mode  of  Growth. — Myomatous  tumours  are  most  variable  in  the 
mode,  direction,  and  rajyidity  of  their  growth.  In  their  mode,  inasmuch 
as  they  may  grow  to  a  certain  size  and  then  either  involute,  atrophy, 
or  generally  shrink  ;  or,  having  attained  a  given  size,  growth  is 
quiescent  for  an  indefinite  time,  when  again  the  tumour  puts  on  a 
phase  of  activity,  and  rapidly  increases.  In  their  direction,  as 
nothing  is  more  common  than  to  find  a  tumour  on  a  first  examina- 
tion occupying  a  defined  position  and  relation  to  the  uterus  before 
it  has  emerged  from  the  pelvis,  and  later  on  becoming  irregular  and 
assuming  a  lateral  one  ;  or  the  mass  projects  backwards,  obliterating 
the  pouch  of  Douglas,  and  compressing  the  rectum ;  or  it  grows 
anteriorly,  displacing  upwards  the  bladder  and  ureters  ;  or  develops 
downwards,  and  approaches  the  vaginal  outlet. 


404  DISEASES   OF    WOMEN. 

Rapidity  of  Growth. — But  in  nothing  does  the  development  of 
a  myoma  vary  more  than  in  its  rapidity  of  growth,  and  this  is  a 
matter  of  such  common  experience  that  it  is  unnecessary  to  dwell 
upon  the  fact.  It  seriously  influences  our  prognosis,  however,  inas- 
much as  the  tumour  which  may  be  borne  with  comparative  comfort 
to-day  may  in  a  year's  time,  or  even  less,  involve  the  bowel,  causing 
obstruction ;  the  bladder,  resulting  in  incontinence  ;  the  kidney,  by 
ui'eteral  pressure ;  or  affect  locomotion,  by  pressure  on  the  sciatic 
nerve.  Myomata  vary  in  consistence,  as  some  are  comparatively 
soft  and  compressible,  others  dense,  and  of  stony  hardness,  depend- 
ing much  on  the  relative  proportion  of  myomatous  or  fibromatous 
structure  present. 

In  a  paper  on  the  '  Biology  of  Fibromyoma  of  the  Uterus,'  Lud- 
wig  Kleinwachter  *  discusses  the  development  of  the  fibro-myoma. 

The  more  muscular  the  tumours  are,  the  more  rapid,  according  to  Gusserow, 
is  the  growth,  which  is  also  dependent  upon  changes  in  the  blood  supply  or 
inflammatory  processes.  Menstruation  frequently  decreases  the  size  of  the 
tumour.  Constriction  of  the  pedicle,  by  causing  oedema,  is  followed  by  in- 
crease. Protracted  illness  may  bring  about  a  decrease  of  the  tumour,  but 
the  general  result  of  his  investigations  would  tend  to  show  that  the  rapidity  of 
growth  varies  considerably  in  different  cases.  Schorler  thinks  that  the  first 
evidences  of  the  commencement  of  the  gi'owth  of  the  tumour  are  not 
observable  before  three  months.  Kleinwachter  draws  the  following  con- 
clusions : — 

'  No  conditions  in  the  growth  of  fibro-myoma  of  the  uterus  are  sufficiently 
strongly  marked  and  regular  to  enable  one  to  determine  the  age  of  a  tumour 
from  its  size.  In  the  generality  of  cases  the  growth  seems  to  be  rapid — only 
in  exceptional  cases  slow.  Occasionally  the  growth  appears  to  advance  by 
leaps  and  bounds.  After  the  tumour  has  increased  very  slowly  for  a  consider- 
able time,  it  suddenly  increases  with  extreme  rapidity,  and  in  a  few  months 
attains  an  excessive  size,  unless  pregnancy  should  intervene.  It  is  only  in 
exceptional  cases  that  a  tumour  comes  to  a -standstill  in  growth,  or  decreases 
in  the  pre- climacteric  years.  It  appears  as  though  ergotine  treatment  aided 
this  result  in  isolated  instances,  but  the  same  thing  might  have  occurred  with- 
out the  use  of  this  remedy.     Wasting  diseases  seem  here  to  play  a  part. 

'  Doubtless  the  original  topographical  position  of  the  tumour  or  its  covering 
is  also  a  weighty  factor  in  the  case.  Influencing  circumstances  should  also  be 
sought,  as,  for  instance,  whether  newly-formed  bloodvessels  are  taken  into 
the  tumour  by  way  of  the  pseudo-membranes  or  not.  In  conclusion,  inflam- 
matory conditions  of  the  periphery  of  the  uterus,  or  inflammation  of  the 
deeper  muscular  tissues  of  the  uteras,  may  both  have  an  influence  on  the 
quicker  or  slower  growth  of  the  tumour.' 

*  ZeiUchrift  f.  Gehurt/hul/e  mid  Gyrmkologie  Trans.  Brit.  Gyn.  Jour.,  Aug., 
1895. 


UTElilNE  NEOPLASMS— MYOMA.  405 

Varieties. — We  may  classify  fibroid  tumours  of  the  uterus — (1) 
according  to  their  pathological  character  :   (2)  their  situation  : 

(1)  Fibroma. 
Fibro-myoma. 
My  o- sarcoma. 
Adeno-myoma. 
Fibro-myxoma. 
Angio-myoma. 
Cystic  myo-sarcoma. 
Myxo-sarcoma. 
Adeno-myxo-sarcoma. 
Cystic  fibro-myoma. 

(2)  Fibroid  tumour  of  the  cervix. 
Fibroid  tumour  of  the  body. 
Situation. 

(a)  Subperitoneal ;  subserous. 

(6)  Submucous. 

(c)  Intra-mural ;  parenchymatous. 

Pozzi  divides  fibrous  tumours  of  the  uterus  under  three  heads.  He  tabulates 
the  three  types  as  follows  :— 

I.  Metritic  (small  interstitial  myoma). 

'  A.  Myoma  of  the  intra-vaginal  portion  of  the 
neck,  sessile  or  pedunculated. 

B.  Submucous  fibromas  of  the  body. 

C.  Pedunculated  fibromas  of  the  body,  or  polypi, 
j^^  ^.„^..„_,  ^^  ^  these  latter  beinp;  (1)  intra-uterine  or  (2) 
the  vaojnia.                    1  .  .  .   °  ^  ^  ,: 

intermittent    in    appearance,   protruding 

from  the  uterus  at  the  time  of  the  cata- 
menia  and  retreating  in  the  intervals ;  and 
(3)  intra-vaginal. 

A.  Pedunculated  fibromas. 

B.  Sessile  fibromas,  not  including  those  in  the 
broad  ligaments. 

C.  Sessile  fibromas,  included  in  -k   Abdominal, 
the  broad  ligaments.  j      Pelvic. 

Subperitoneal  tumours  are  attached  to  the  wall  of  the  uterus 
either  by  a  pedicle  or  by  a  broad  base.  The  tumour  pushes  the 
peritoneum  before  it.  It  may  become  detached  from  the  uterus, 
or  remain  attached  to  it  by  a  long  pedicle  composed  of  peritoneum 
and  connective  tissue.  The  submucous  grows  into  the  uterine 
cavity.  If  it  be  pedunculated,  it  is  known  as  fibrous  polypus.  If 
parenchymatous,  it    may  be  single  or  conglomerate,  encapsuled    or 


II.  Type  developing  toward 


^ 


III.  Type  developing  toward 
the  abdominal  cavit}' 
(subperitoneal  or  inter- 
stitial). 


406  DISEASES   OF   WOMEN. 

non-encapsuled.  The  conglomerate  may  be  formed  by  the  fusion  of 
a  number  of  small  fibroid  masses,  which  give  to  the  tumour  a  lobu- 
lated  appearance.  They  may  lie  in  a  capsule  of  cellular  tissue,  or 
they  may  be  simple  outgrowths  from  the  uterine  wall,  and  continuous 
with  and  devoid  of  any  capsular  investment. 

Degenerations. — Though  in  the  last  edition  of  this  work  I  referred 
specially  to  degenerative  changes  in  myomata,  the  subject  has  been 
more  fully  discussed  within  the  last  few  years,  and  evidence  has 
accumulated  to  prove  that  such  degenerations  are  far  more  frequent 
than  was  previously  thought. 

This  classification  of  degenerations  and  complications  of  myomata 
is  complete,  so  far  as  our  present  knowledge  enables  us  to  say. 

Degenerative  Complications. 


/Mucoid. 
Colloid. 
Calcareous. 
Sarcomatous, 
(a)  Degenerative     changes    in  I  Suppurative, 
the  tumour.         .  .    \  Gangrenous. 


— "»' • 

Necrobiotic. 
Telangiectatic. 
Adeno-carcinomatous. 
1^  Adiposis. 


(h)  Adnexal  complications 


Extra-uterine  Complications. 

/Inflammatory  and  adhesive. 
I  Suppurative. 
I  Tubercle. 
\  Cystic. 

Solid  benign  growths. 
\  Solid  malignant  growths. 

f  Obstruction.     Appendical. 

(c)  Bowel  complications  •     I    a  ju     •  J    Omental. 

I  j^dnesions    s  i  •     i 

[  [   Intestinal 

/  (  TD  1   •       r  Acute. 

/        .       .  .    )  Pelvic    I  ^,  , 
,^,-^,.,         1  T     ..  Peritonitis]  „  -,{  Subacute. 

(a)  Peritoneal  complications  .    '  '  General  j 

\  -  \  Septic. 

V  Ascites. 


UTEA'/NJ-J   NEOfLA .SM.-^—M  VGA/ A. 


407 


(e)   Vesical,  renal,  and  ureteral 
complications 


(/')  Circulatory  complicatious 


(g)  Those    arising    from    pre^ 
nancy 


/' 


Displacement  of  the  bladder  and 

ureters. 
Adhesions. 

Obstruction  of  ureter. 
Hydro-ureter. 
Hydronephrosis. 
Pyonephrosis. 
,  Albuminuria. 

Haemorrhage. 

Amemia, 

Cardiac  complications. 

Abortion. 
Miscarriage. 
Ectopic  gestation. 
Rupture  of  the  uterus. 
Malpresentations. 
Dystocia. 

Obstructed  labour. 
Postpartum  haemorrhage. 


Psychical  Complications. 


(A)  Mental  effects  . 


(t)  General  consequences 


The  disorder  of  mentalization  may 
vary  in  degree,  from  the  neur- 
asthenic or  hysterical  state  to 
phases  of  melancholia,  de- 
mentia, or  mania. 

Under  this  head  we  may  include 
such  consequences  of  pressure, 
as  difficulty  in  walking ;  iniiam- 
matory  changes  in  the  tumour 
due  to  exposure  or  traumatism ; 
interference  with  health,  con- 
sequent upon  pain,  weight  of 
tumour,  constipation,  urinary 
disturbance,  and  the  depression 
and  apprehension  caused  by  the 
presence  of  the  tumour. 


408  DISEASES  OF    WOMEN. 

Torsion  of  the  Uterus. — This  is  comparatively  a  rare  condition.  Ehrendorfer 
ascribes  it  to  the  resistance  offered  to  the  growth  of  tlie  tumour  caused  by  the 
obstruction  from  the  pelvic  wall.  The  presence  of  an  ovarian  tumour  predis- 
poses to  it,  still  more  so  if  the  ovarian  tumour  be  associated  with  pregnancy. 
The  ovaries  are  also  frequently  displaced,  and  out  of  position.  Torsion  gives 
rise  to  such  complications  as  congestion  and  fibromitis,  necrosis  of  the  tumour, 
and  peritonitis. 

Degenerations. — In  the  Edinburgh  Medical  Journal  of  1900,  I  discussed 
the  subject  of  myoma  and  its  degenerations,  and  the  bearing  of  the  latter  on 
the  question  of  operation,  side  by  side  with  the  complications  mentioned  in 
the  text.  The  degenerative  changes  I  then  summarized  were  those  given 
in  the  table,  p.  406. 

At  the  meeting  of  the  British  Gynaecological  Society  (July  11,  1901)  I 
collected  the  following  examples  of  degenerative  changes  in  myoma  : — Cystic 
degenerations,  10;  myxomatous  (mucoid),  2;  necrobiotic,  4;  calcareous,  5 ; 
cystic  adenoma,  1 ;  telangiectasis,  1 ;  suppuration,  2  ;  malignant  '  soft  adeno- 
matous '  (■?),  3 ;  carcinomatous,  2.  These  specimens  were  exhibited,  at  my 
request,  by  William  Duncan,  Handfield  Jones,  Mayo  Robson,  the  Master  of 
the  Rotunda  (Purefoy),  Charles  Ryall,  B.  Jessett,  Mary  Scharlieb,  A.  Giles, 
Cheatle,  and  Stanley  Boyd. 

At  that  time  I  had  the  museums  of  the  large  London  hospitals,  and  that 
of  the  College  of  Surgeons,  searched  for  examples  of  degeneration,  with  the 
following  results  : — 

In  the  Museum  of  the  Royal  College  of  Surgeons  of  England  there  were  in 
all  47  specimens  marked  definitely  as  fibrous  tumours  of  the  uterus.  Of  these, 
33  are  described  as  having  undergone  ulceration,  degeneration,  or  been  com- 
plicated by  adhesions,  pregnancy,  or  ovarian  tumours.  These  we  may  divide 
as  follows  : — Pressure  of  ureters,  1 ;  ulceration  of  the  tumour,  3 ;  ulceration 
of  the  vagina,  1 ;  calcification,  3  ;  cystic  degeneration,  1 ;  with  complications 
of  the  adnexa,  6 ;  with  pregnancy,  5. 

In  St,  Bartholomew's  Hospital  Museum  there  were  examples  of  the  follow- 
ing degeneration  and  complications : — ^Cystic  degeneration,  3 ;  calcification, 
2  ;  myoma  complicated  with  diseases  of  the  adnexa,  5;  myoma  with  cancer, 
1 ;  degenerating  myoma  with  cavity  containing  serous  fluid,  1. 

In  University  College  Hospital  Museum  there  were  the  following : — slough- 
ing myoma,  1  ;  fungoid  degeneration  with  ulceration,  1 ;  suppurating  myoma 
with  calcareous  degeneration,  1 ;  calcareous  degeneration  with  adnexal  com- 
plications, 2  ;  calcareous  degeneration  alone,  5. 

In  the  Westminster  Hospital  Museum  there  was  one  specimen  of  cal- 
careous degeneration.  In  St.  George's  Hospital  Museum  there  are  4 
specimens  of  calcareous  degeneration  of  myoma,  2  of  myoma  complicated 
with  pregnancy,  1  of  myxomatous  degeneration,  and  1  of  fibro-cystic 
degeneration. 

On  this  search  I  commented — 

'  The  search  in  the  various  museums  establishes  the  contention  that  discus- 
sions on  the  surgical  treatment  of  myoma  of  the  uterus  have  been  in  a  sense 
hitherto  conducted  in  the  dark ;  countless  specimens  have  been  exhibited 
without  any  pathological  examination  having  been  made,  in  many  instances 


UTERINE  NEOPLASMS— MYOMA.  409 

not  even  cut  open — exhibited  as  evidences  of  surgical  skill  and  triumph,  and 
often  not  even  of  the  latter.  The  day  has  gone  by  for  the  presentation  of  a 
tumour,  no  matter  what  its  size,  unless  its  pathological  significance  be  at  the 
same  time  illustrated  and  exposed.' 

Charles  Noble  (who  read  a  paper  on  the  subject)  recorded  the  results  of 
the  examination  of  218  cases  of  fibro-myomas.  He  found  as  a  result  that 
about  one-third  would  have  died  from  the  complications  or  degenerations 
present.  He  also  arrived  at  these  conclusions : — The  disappearance  of  the 
myoma  as  a  result  of  the  menopause  is  not  to  be  expected.  Adhesions, 
anaemia,  thrombus,  phlebitis,  and  sarcomatous  degeneration  are  special 
dangers.  While  the  mortality  from  hysterectomy  is  2-10  per  cent,  that 
arising  from  the  tumour  is  some  33"3  per  cent.  He  has  since  *  again 
revised  tlie  subject  of  '  the  risks  encountered  by  patients  suffering  from  fibroid 
tumours,'  whether  those  of  a  fatal  nature  or  threatening  life,  or  those  which 
involve  invalidism.  He  gives  the  presumptive  mortality  from  complications 
and  degenerations  from  an  analysis  of  688  cases  of  fibro-myomata  recorded 
by  Martin,  Xoble,  Frederik,  and  Cullingworth.  at  16-24  per  cent,  arising  from 
the  tumour  itself,  and  some  45  per  cent,  if  we  include  extra-uterine  complica- 
tions -which  were  present.! 

ProchownickJ  says  that,  upon  investigating  all  the  cases  of  uterine 
myomata  that  he  had  met  with  in  the  course  of  the  last  twenty-five  years,  he 
had  found  that,  even  with  the  most  careful  and  painstaking  conservative 
treatment,  barely  three-fifths  of  the  sufferers  had  been  conducted  past  their 
climacteric,  and  then  remained  permanently  cured.  In  the  other  two-fifths, 
operation  became  a  matter  of  necessity,  in  many  after  the  normal,  in  some 
after  an  artificial,  menopause ;  of  32  castrated  women,  9  had  to  undergo  a 
subsequent  operation.  At  the  same  time,  he  declared  that  the  indications  for 
interference  were  to  be  deduced  from  persistent  study  of  the  anatomy  of  these 
tumours  and  from  clinical  observation,  aided  by  all  modem  means  of  research, 
and  not  from  the  improved  technic  and  better  prognosis  of  operation. 

He  enumerated  and  illustrated  by  specimens  the  following  kinds  of 
degeneration : — 

1.  Simple  systemic  degeneration  without  alteration  of  the  morphological 
stnicture  of  the  tumour ;  due  entirely  to  the  clinical  eftects  of  the  growth, 
generally  to  the  haemorrhage  (anaemia,  hydremia,  heart  affections),  less 
frequently  to  pressure  or  tension  (bladder,  ureters,  kidneys). 

2.  Degeneration  of  the  tumour  : 

(a)  Innocent  and  relatively  normal  changes — atrophy,  calcification,  adiposis. 
(6)  Degenerations  anatomically  innocent,  but  clinically  malignant. 

*  American  Gynecology,  April,  190c!. 

t  In  quoting  Boldt,  Montgomery,  and  Kelly,  Xoble  says :  '  So  far  as  test-books 
are  concerned,  the  classical  teaching  about  Hbro-myomata  is  still  perpetuated,  viz. 
that  these  tumours  are  benign  in  character,  that  they  usually  produce  no  symp- 
toms, that  their  chief  danger  consists  in  their  tendency  to  produce  hsemorrhage, 
and  that  after  the  menopause  they  tend  '•  to  shrink  and  disappear."  I  must  here 
enter  a  protest,  for  this  is  just  the  opposite  of  that  enforced  in  the  eighth  edition 
of  this  work. 

I  Munch,  m.  ]\chns.,  1901,  No.  19. 


410  DISEASES   OF    WOMEN. 

Of  these  latter  a  considerable  number  are  originally  due  to  the  clinical 
effects  of  the  tumour  before  it  has  undergone  any  change  (alteration  in  the 
composition  of  the  blood  from  haemorrhage).  Acute  forms  are  uncommon 
(torsions,  thromboses,  hsemorrhagic  infarcts,  accidental  infection  or  gangrene, 
generally  due  to  therapeutic  measures).  Sub-acute  forms  are  not  so  rare 
(necrobioses,  which  clinically  and  anatomically  are  analogous  to  a  dead 
foetus).  Chronic  forms  are  more  often  seen  (fibrinous,  myxomatous  and 
cystic  degeneration).  Telangiectatic  and  mechanically  inflamed  myomata 
(with  or  without  chronic  infection)  also  belong  to  this  category. 
(c)  Degenerations  anatomically  malignant. 

Prochownick  held  that,  when  associated  with  myoma,  sarcoma  is  due  to 
metaplasia,*  carcinoma  to  invasion  from  without. 

Clinically,  a  distinction  must  be  made  between  the  degenerations  which 
occur  before  and  after  the  menopause  ;  the  latter  are  always  more  serious  and 
of  more  unfavourable  prognosis,  and  operation,  if  to  be  done  at  all,  should  be 
done  early. 

The  gradual  progress  of  systemic  degeneration  can  be  accurately  observed 
by  repeated  examination  of  the  blood  (estimation  of  the  hsemoglobin  before 
and  after  the  menstrual  flow,  enumeration  of  the  red  corpuscles,  leucocytosis, 
and  charting  the  hsemon'hage  curve).  A  decrease  of  the  haemoglobin  below 
65  or  60  per  cent.,  or  of  the  red  corpuscles  below  2,500,000  without  recovery 
in  the  interval,  is  an  urgent  indication  for  interference,  as  also  is  a  slow 
but  steady  fall  in  the  number  of  red  corpuscles  with  a  constantly  decreasing 
recovery  between  the  bleedings. 

In  morphological  degeneration  also,  even  if  the  patients  do  not  suffer  from 
very  serious  hsemorrhage,  regular  examinations  of  the  blood  are  of  much 
clinical  importance ;  a  slow  fall  in  the  figures,  and  alterations  in  the  leuco- 
cytes, accompany  all  chronic  changes  in  the  tumours. 

As  points  to  which  special  attention  should  be  directed,  Prochownick 
instanced — the  seat  and  number  of  the  tumours  and  their  arrangement  in  and 
about  the  corpus  uteri ;  their  growth  and  consistence,  any  sudden  or  rapid 
enlargement  being  very  ominous  ;  any  change  in  the  type  of  the  catamenia  ; 
pains,  which  at  their  onset  are  generally  due  to  tension  upon  the  parietal 
peritoneum,  and  then  always  suggest  the  presence  of  some  inflammation  ; 
the  urine — a  specimen  taken  with  the  catheter — should  be  examined  fre- 
quently, renal  irritation  almost  invariably  occurring  early  in  anatomical 
changes,  even  in  those  at  first  innocent.  Alteration  in  the  shape  of  the  heart 
and  in  the  quahty  of  the  pulse  are  associated  with  every  form  of  degenera- 
tion ;  and  the  weight  and  specific  heat  of  the  body,  the  fundus  of  the  eye,  the 
facial  expression,  the  condition  of  the  skin,  and  the  appearance  of  ascites  are 
not  to  be  neglected.  Degeneration  of  a  myoma  is  not,  any  more  than  other 
malady,  betrayed  by  one  symptom,  but  by  the  concurrence  of  several. 

*  Haemangio-eadothelioma  Intravascular. — A  mass  .weighing  fifteen  pounds 
has  been  removed  from  the  neck  of  the  uterus,  the  microscopical  appearances  of 
which  showed  that  it  originated  from  the  epithelium  of  the  vessels  of  the 
uterine  wall.  In  structure  it  closely  resembled  sarcoma,  but  there  were  no  me- 
tastases.    (^Vircliow  Archie,  bd.  clxxi.,  heft  i.) 


PLATE   XXX. 


Dual  3Iyoi[a  of  the  Uteeus — Necrobiosis  a>-d  Mucoid  -vitb.  CALCAREors 
Degexeratiox.    (Author.) 

'There  were  no  urgent  symptoms.  The  patient  was  otherwise  in  good  health, 
but  the  tumour  was  perceptibly  increasing  in  size.  Operation  was  decided 
upon,  and  supra-vaginal  hysterectomy  performed.  On  section,  a  consider- 
able necrotic  area  was  found  in  the  Tipper  myoma  bounded  by  a  zone  of 
calcareous  degeneration,  and  the  canal  of  the  uterus  greatly  enlarged  and 
full  of  mucoid  fluid.  [To  face  p.  410. 


UTERINE  NEOPLASMS— M yiiM A.  411 


Fiv-enkel  confirmed  the  results  of  Procliownick's  investigations  from  his 
own  experience  in  the  post-mortem  room.* 

Fibro-cystic  Tumours — Etiology.f 

Mary  Dixon  Joues  lias  recently  written  on  the  etiology  of  fibro-cystic 
tumours  of  the  uterus.J  As  we  have  akeady  shown,  cystic  degeneration  is 
not  an  uncommon  sequence  of  a  myomatous  growth  in  the  uterus,  hut  cases 
in  which  large  cysts  are  found  in  a  myomatous  tumour  are  comparatively 
rare.  This  was  the  experience  of  such  operatoi-s  as  Pean,  Spencer  Wells,  and 
Clay.  Individual  cases  have  been  reported  from  time  to  time,  and  several 
in  which  the  tumour  was  mistaken  for  ovarian  cystoma,  as  many  as  thirty 
pints  of  fluid  being  contained  in  the  cyst.§  Skene  Keith  recently  showed,  at 
the  British  Gynaecological  Society,  a  huge  fibro-cyst.  The  tumour  weighed 
36  lbs.,  and  was  taken  ft-om  a  single  woman  set  30.  :Mr.  Keith  had  seen  her 
ten  years  previously.  The  tumour  was  then  small,  and  it  was  decided  not  to 
interfere.  With  the  cessation  of  menstruation,  the  tumour  decreased  in  size, 
and  then  remained  stationary  until  eighteen  months  before  the  operation, 
when  it  began  to  increase  rapidly,  until  it  attained  to  the  size  mentioned. 
There  was  no  microscopical  examination  in  this  case,  but,  when  the  tumour 
was  cut  into,  it  consisted  almost  entirely  of  one  enormous  cystic  cavity  full 
of  broken-down  debris  in  mucoid  fluid. 

Another  such  case  was  reported  by  "Worrall  of  Sydney,  in  which  the  cystic 
myoma  weighed  38  lbs.  The  patient  from  whom  it  was  removed  was  set.  42, 
and  the  cavity  contained  some  2  gallons  of  dark  brown  fluid,  in  which  floated 
great  ropes  of  disintegrating  fibro-muscular  tissue.  In  this  instance  the 
tumour  appeared  to  have  been  gi-owing  for  nine  years,  but  the  great  increase 
in  size  had  occuiTed  within  the  last  eighteen  months.  In  many  the  cystic 
degeneration  was  mingled  with  calcareous  and  suppurative  changes.  Mary 
Dixon  Jones,  who  so  far  back  as  1886  was  studvang  the  nature  of  these 
tumours,  quotes  the  view  of  Pean,^  that  the  cyst  may  be  due  to  (1)  the 
deliquescence  of  a  portion  of  a  fibroma,  or  (2)  the  dilatation  of  the  lymphatics 
and  the  formation  of  sinuses  at  the  extremities  of  the  several  vessels.  The 
first  of  these  views  was  accepted  by  Virchow.  Klebe  attributed  them  to 
hydropsia  and  cedema.  The  view  of  lymphatic  dilatation  was  advocated  by 
Bilroth  and  Koeberle,  the  lymphangeomatous  nature  of  the  tumour  lending 
force  to  the  supposition,  as  also  the  rich  peripheral  supply  of  lymphatics.  The 
authoress  does  not  accept  this  explanation,  and  she  regards  the  new  cystic 


*  At  a  meeting  of  the  British  Medical  Association  at  Ipswich,  in  1900, 
Harrison  Cripps  referred  to  the  frequency  -ssith  which  cystic  and  mucoid 
degeneration  occurred  in  myomatous  tumours  of  the  uterus,  and  I  then  urged 
the  need  for  recognition  of  the  special  dangers  arising  out  of  these  and  other 
degenerative  changes. 

t  See  also  p.  432  for  differentiation. 

X  Med.  Bee,  Oct.  10,  1903. 

§  Dub.  Quart.  Jour.,  Aug.  1,  1864. 

^  '  Pathology  of  Tmnours,'  vol.  iii.,  p.  399. 


412 


DISEASES   OF    WOMEN. 


formations  as  a  consequence  of  medullary  changes  in  the  tissues  and  new 
formations  eventuating  from  this  medullary  condition.  The  cyst  is  a  develop- 
ment from  the  medullary  material. 
She  takes  the  view  that  a  fibroid 
tumour  is  a  diseased  condition 
arising  out  of  an  inflammatory  cor- 
puscular change  in  the  tissues  of  the 
uterus ;  that  fibroid  tumours  do  not 
cause  degeneration,  but  that  de- 
generation arises  from  the  secondary 
processes  of  disease  developed  in 
the  tumour  or  in  the  uterus;  and, 
further,  that  infection  of  the  adnexa 
is  carried  from  the  tumour  to  the 
ovaries  and  tube.  She  supports  her 
contention  by  a  number  of  micro- 
scopical researches  into  the  nature 
of  the  fibro-cystic  degeneration, 
in  which  she  found  inflammatory 
•^  \  m  changes  in  the  tissues  with  the  pre- 

fer &  ^  sence  of  granules  and  inflammatory 

corpuscles,  sometimes  osseous  de- 
generation, another  time  pus,  these 
being  associated  with  sinuous  cystic 
canals  or  irregular  cavities.  In 
some  the  changes  partook  of  the 
endotheliomatous  nature,  and  blood 
cysts  were  present.  The  gi'anules 
present  were  derived  from  the  in- 
flammatory corpuscles  w^hich  in 
their  tm'n  were  developed  from  a 
metamorphosis  in  the  normal  tissue. 
The  important  question,  whether 
myoma  of  the  uterus  may  degenerate 
into  a  sarcoma,  must  be  answered 
in  the  affirmative  (see  chapter  on 
Cancer).  Virchow,  Schroeder,  and 
Martin  (not  to  mention  many  others) 
believe  that  such  a  metamorphosis 
does  occur.  In  fact,  it  is  regarded 
hy  some  as  the  rule  in  cases  of 
sarcoma.  David  Finley  recorded  such  a  case  before  the  Pathological  Society 
of  London,  in  which  the  tumour  was  encapsuled,  as  is  the  case  in  uterine 
myoma.  This  patient  had  noticed  a  hard  swelling  in  the  abdomen  for  fifteen 
years  before  the  rapid  increase  occuiTed  that  called  for  interference.'  f 

Alban  Doran  discussed  the  entire  question,  and  exhibited  a  tumour  in  which 

*  Jour.  Obst.  and  Gyn.  Brit.  Emp.,  Aug.,  1903. 
t  Trans.  Path.  Soc,  vol.  xxis.,  1883,  p.  177. 


Fig.   278. — Giaxt    Cystic    Fibi;o-mto- 

M.VTA    OF   IjTERrS,  WEIGHING   ElGHTT- 

SEVEN  Pounds,  about  Half  the 
ENTIRE  Body  Weight  removed  suc- 
cessfully FROM  A  Patient,  Aged 
Forty-one  Years.  (Clarence  Web- 
ster, Chicago.*) 

The  operation  lasted  two  hours  and  a- 
half,  was  conducted  with  the  woman 
in  an  analg£esic  condition  (partial 
anaesthesia  with  the  Schleich  mixtm-e 
in  the  skin)  and  heat  maintained  by 
the  electric  pad. 


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PLATE   XXXII. 


Cysto-sarcojia  of  the  Uterus,  with  Associated  Necrobiotic  axd  ]Mucoid 
Degeneration  suerouxded  by  the  MuscrLAK  Structure  of  the  Uterus. 
(W.  B.  Jessett.) 

PLATE   XXXIII. 


Subserous  Fibroid  of  Uterus  with  Myxoiiatous  Degeneratiox.     (Author.) 

The  entire  substance  of  the  tumour  was  converted  into  myxomatous  tissue,  with 
cavities  here  and  there  filled  with  mucoid  fluid. 

[To/ace  p.  413. 


Xo.  I.  sbo-wiug  inflammatory  area,  fibro-cystic  formation,  and  bloodvessels. 


if^-f'^^fW^    '^'-'^^  .c-1^>»::'^'^%L^ 


.?-!  - 


ir-js' 


BEi*siS£«i^ 


No.  II.  shovidng  fibro-cystic  formation  with  inflammatory  corpuscular  areas. 


No.  in.,  showing  granules  from  inflammatory  corpuscles  with  some  blood 
corj^uscles,  canal  cysts,  and  blood  cysts. 


No.  lY.,  showing  the  same  granules,  canals,  and  blood  cysts. 
Fig.  279.— Seotioxs  from  Fibro-cystic  Myoma.    QIary  Dixon  Joxes.) 


414 


DISEASES   OF   WOMEN. 


such  transitional   changes   appeared  to   be   occurring   at   the   time   of    le- 
moval : — 

'  The  tumour  was  practically  an  expansion  of  the  fundus,  lying  in  its  walls, 
which  thus  formed  the  capsule.  Elsewhere  the  uterine  walls  were  soft  and 
very  thick,  entirely  free  from  interstitial  fibroids.  Thus  the  tumour  was 
sohtary.  A  phlebolith,  in  appearance  like  an  oval,  semi-transparent,  yellow 
pebble,  one-eighth  of  an  inch  long,  lay  under  the  serous  coat  of  the  uterus 


Fig.  280. — Section  of  the  Tumour, 
SHOWING  Bundles  of  Well  - 
FORMED     Plain     Muscle-cells. 


Q"  objective.) 


Fig.  281. — Another  Part  of  same 
Section,  showing  Shorter  Fusi- 
form Cells  with  Large  Oval 
Nuclei. 


posteriorly.  Pure  fibrous  tissue  was  practically  absent.  Uterine  muscle-cells 
abounded.  They  formed  thick  bundles,  and  each  cell  was  very  elongated, 
and  bore  a  long,  narrow  ("  staff-shaped  ")  nucleus.  Groups  of  cells  of  a 
different  type  were  also  present.  They  were  quite  as  distinct  as  the 
muscle-cells,  but  shorter  and  much  thicker.  The  nuclei  were  distinctly  oval 
and  wide  in  the  middle.  The  two  varieties  of  cell  above  described  are 
represented  in  the  drawings.'  * 

From  a  number  of  sources  have  come,  within  recent  years, 
authentic  reports  of  this  transition  of  uterine  neoplasms  into 
sarcomatous  tissue.  A  typical  case  was  reported  by  Goffe  t  where 
a  symmetrical  tumour,  four  pounds  in  weight,  was  found  infiltrated 
with  fibro-sarcomatous  tissue  and  a  necrotic  sarcomatous  mass 
filling  the  uterine  cavity.  Edge  and  Christopher  Martin  met  with 
four  cases  of  sarcomatous  degeneration  of  myoma,  and  Doyen  and 
Schauta  have  also  recorded  several  cases  of  sarcomatous  and  malignant 
degeneration  in  the  cervix  after  supra- vaginal  hysterectomy. 

Jessett  says :  '  With  respect  to  myomata  taking  on  sarcomatous 
growth,  there  can  be  no  doubt.'  He  has  had  six  or  seven  such 
cases.     (See  Plate  XXXIV.) 

That  malignant  degeneration  may  arise  in  the  uterine  tissue,  is 
proved  by  the  number  of  cases  of  sarcoma  and  carcinoma  occurring 
in  the  uterine  stump  remaining  after  supra-vaginal  hysterectomy. 
Before  1901  forty  such  cases  had  been  recorded  by  the  following 
operators  alone — Schauta,  Schenk,  Menge,  Doyen,  Wehmer,  Flatau, 

*  Trans.  Path.  Soc,  1890. 

t  Amer.  Jour.  ObsteL,  April,  1902. 


PLATE   XXXIV. 


Telaxgiectatic  Myoma.    (Pukefoy.) 

Patient,  aged  52,  niimarried;  liad  severe  attack  of  peritonitis,  lasting  6  weeks; 
large  abdominal  tumour  discovered  while  under  treatment ;  was  operated 
upon  at  the  Kotunda  Hospital.  There  were  numerous  omental  adhesions, 
the  separation  of  which  caused  much  haemorrhage.  The  abdominal  wall 
was  firmly  incorporated  with  the  anterior  surface  of  a  large  fibroid,  con- 
nected with  the  left  cornu  of  the  uterus  bj^  a  small  pedicle. 

On  section,  the  substance  of  the  tumour,  except  a  small  portion  near  the  pedicle, 
was  found  to  be  of  a  dark  rod  colour,  and  was  hollowed  out  into  large 
cavities  freely  communicating  and  containing  unaltered  blood  in  large 
quantities.  Dr.  Earle  reported  as  follows  oa  the  microscopical  appear- 
ances : — '  The  tissues  of  the  tumour,  though  so  unusual  in  colour,  did  not 
show  degenerative  changes,  but  stained  in  the  usual  way,  and  the  numerous 
cavities  having  a  very  smooth  lining  membrane  appeared  to  be  dilated 
bloodvessels.'  This  condition  in  a  myoma  is  of  great  rarity,  and  very  few 
instances  of  it  have  as  yet  been  rei^orted  in  this  country. 

ITo  face  p.m. 


PLATE   XXXY. 


Section  of  Poetion  of  Myoma,  shoavixg  Central  Area  of  Calcification, 
THE  Result  of  Hyaline  Degeneration. 

The  tumour  removed  Ly  myo-hysterectomy,  showed  in  section  a  centrararea  of. 
calcification,  in  the  centre  of  which  was  a  small  calcified  mass.  Within  a 
hyaline  patch  some  thick-walled  vessels  containing  organized  blood-clot 
are  seen.  A  hard  nodule  from  another  part  of  the  growth  has  been 
decalcified  and  examined.  It  shows  that  the  calcareous  deposit  has  been 
laid  down  in  j^arts  of  the  fibroid  which  have  jDreviously  undergone  the 
hyaline  change  above  referred  to.  Such  hyaline  degeneration  is  likewise 
associated  with  the  calcification  iDresent  in  some  forms  of  carcinoma. 

PLATE   XXXVI. 


Area  of  Hyaline  Degeneration,  with  Process  of  Calcification 

Proceeding.  ^To  face  p.  4:15. 


rTEETXE  XEOPLA ^"^M^t— MYOMA. 


11. "i 


Jacobs,  Saver,  Christopher  Martin,  and  Edge.*  Flatau,  out  of 
104  cases  of  myomata,  under  his  charge,  found  that  five  had  under- 
gone sarcomatous  degeneration. f  He  is  of  opinion  that  the 
sarcoma  is  developed  from  the  cells  of  the  connective  tissue  stroma. 
In  none  of  his  specimens  did  he  find  the  transition  of  normal 
myocytes  into  sarcoma  cells,  of  various  size  and  colour  with 
irregular  nuclear  forms  in  myoblasts.  Carcinomatous  degeneration 
of  myomata  he  considers  is  due  to  gi'owth  of  the  epithelial  mucosa 
into  the  myoma,  or  by  proliferation  of  epithelial  elements  of  mis- 
placed fragments  of  organs.  Malignant  degeneration  he  does  not 
think  has  any  special  influence  on  the  indications  for  operation. 

Adeno-myoma. — Out  of  an  examination  of  seven  hundred  cases 
of    uterine    myoma    Cullen  %   found  nineteen   specimens  of   adeuo- 


/    \ 


Fig.  282. — Ahexu-MA  uf    rui:   L'Tina-.     (J^axkac.) 
a,  adenoma  of  body ;  6,  fibromatous  noLlule ;  c,  cervix. 

myoma.     The  condition  is  most  frequently  met    with   during  the 
child-bearing  period.     Cullen  leans  to  the  view  that  this  neoplasm 

*  Brit.  Gyn.  Jour..  :May.  1001. 
t  Miinrh.  m.  Wchng.,  1901,  Xo.  14. 
%  Amer.  .V^f?.  Jour..  July  5.  1902. 


416  DISEASES  OF   WOMEN. 

is  not  due  to  remains  of  the  Wolffian  duct,  but  to  the  uterine 
mucosa  or  a  portion  of  Miiller's  duct.  The  uterine  mucosa 
extends  by  continuity  into  the  neoplasm ;  while  here  are  found 
glands  resembling  uterine  glands  in  a  characteristic  stroma,  the 
Wolffian  body  contains  no  structures  that  can  be  mistaken  for 
uterine  glands.  Cullen  divides  the  growth  into  three  main  groups. 
(1)  The  uterus  is  as  a  rule  enlarged,  more  globular  in  shape,  or 
somewhat  irregular  in  outline  from  small  superficial  myomata. 
There  is  a  tendency  to  fixation  of  the  uterus  from  adnexal  and 
peri-uterine  adhesions.  Profuse  menstruation  is  a  consequence. 
The  other  two  groups  are  (2)  the  subperitoneal  or  intra-ligamentary  ; 
and  (3)  the  sub-mucous.  The  differentiation  of  all  these  growths 
from  simple  myoma,  or  a  sarcoma,  is  extremely  difficult,  if  not 
impossible,  before  removal. 

Fig.  284  is  taken  from  a  specimen  of  Leopold  Landau's.  The  case  was 
diagnosed  as  one  of  myoma.  At  operation  both  appendages  were  found 
diseased,  at  the  left  side  there  being  a  tubo-ovariau  blood  cyst,  with  a  hjqDer- 
trophied  and  convoluted  tube,  the  ovary  being  papillomatous,  and  on  the  right 
side  a  hsemato-salpinx  14  cms.  long,  and  a  large  cystic  ovary.  Landau 
describes  the  uterus  thus  :  '  It  weighs  over  2  kilos,  is  uniformly  enlarged,  and 
is  divided  by  a  sagittal  suture.  It  is  19  cms.  long,  the  uterus  measuring  4 
cms.,  the  cavity  being  represented  by  a  gaping  slit.  The  uterus  has  grown  in 
two  distinct  layers — an  inner  kernel  zone,  which  attains  a  maximum  thickness 
of  7  cms.  anteriorly  and  4*5  cms;  posteriorly,  and  a  shell  of  an  average  thick- 
ness of  1  cm.,  becoming  a  little  thicker  near  the  internal  os.  The  latter  con- 
sists of  concentrically  lamellated  myometrium ;  the  greater  portion  of  the 
kernel  mass  consists  of  a  coarse  reticulated  trellis-work  of  relatively  broad 
muscular  bundles,  which  is  thrown  into  relief  by  the  sinking  in  of  the  con- 
nective tissue  lying  in  the  meshes.  The  bundles  are  disposed  for  the  most 
part  in  the  circles  or  crescents  round  the  tissues  in  the  meshes.  The  latter 
appears  darker  and  more  spongy,  and  shows  either  notched  and  pit-like 
depressions,  from  a  pin-point  to  a  pin-head  in  size,  or  else  circular  or  more 
irregular  cysts,  and  elongated  spaces  up  to  the  size  of  a  pea,  and  all  lined 
with  a  smooth  inner  wall  like  mucous  membrane,  and  occasionally  containing 
reddish-brown  fluid  masses.  Even  to  the  naked  eye  it  is  evident  that  the 
tissue  in  the  meshes  is  directly  continuous  with  the  mucosa  of  the  cavity  of 
the  body  of  the  uterus,  and  represents  an  extension  of  the  same  into  the 
uterine  parenchyma,  for  the  elongated  and  cj^st-Hke  spaces  open  free  into  this 
cavity.  In  con-esponding  fashion  there  is  microscopically  no  difference  be- 
tween the  corporeal  mucosa  and  the  interfascicular  tissue  of  the  central  mass. 
In  the  spread-out  covering  of  the  central  tumour  rnass,  which  invests  the 
whole  cavity  like  a  tube  or  mantle,  can  be  readily  recognized  the  myometrium. 
This  has  become  reduced  to  the  slender  shell  above  described ;  and  it  is 
easy  to  trace  how,  out  of  its  parallel  concentric  lamellae,  crescentic  muscular 


Fig.  283.— Adenoma  Universale.  (Oliver.)  Uterus  of  patient,  aged  3i  ;  virgin. 
Two  mucous  polyi^i  were  removed  from  au  enlarged  uterus,  and  a  tliird  two  years  later,  when 
the  uterus  was  dilated  explored,  aud  curetted.  Watery  discharges  followed,  with  increase  in  the 
B^  ot  the  tumour.  The  patient  was  re-curetted,  aud  subsequently  the  uterus  was  removed  by 
abdominal  pan-by.stei;ectomy.  AVeight  of  uterus,  twenty-eight  ounces  :  size,  that  of  a  three 
months  pregnancy.  The  figure  shows  the  uterus  opened  by  a  triangular  flap,  made  from  the 
ce.vix  to  the  tundus,  and  the  enormous  number  of  smooth  prominences,  some  sessile,  a  few 
pedunculated.  The  new  growth  had  quite  infiltrated  the  muscular  tissue.  The  microscopical 
appearances  were  typical  of  carcinoma.  Oliver  gives  to  the  pathological  condition  the  name  of 
adenoma  universale,  rather  than  that  of  malignant  adenoma.  The  history  of  the  case  would 
point  to  the  disease  having  lasted  for  some  years.* 


Brit.  Gyn.  Jour.,  May,  1899. 


2    E 


418  DISEASES    OF    WOMEN 

bands  Lave  spread  out  in  all  directions,  and  extended  in  tortuous  fashion 
into  the  muscular  framework  of  the  core  of  the  tumour. 
'  The  patient  was  discharo-ed  cured  in  a  month.' 


iv 


:  / 


// 


\ 


/ 


Fig.  28i. — Adenoma  of  the  Uterus  diagnosed  as  Myoma. 
(Leopold  Landau.) 

Murdoch  Cameron  and  Frank  1'aylor  operated  on  a  case  in  which  the 
macroscopical  appearances  were  those  of  an  ordinary  fibro-myoma,  the  length 
of  the  uterus  being  5  inches,  breadth  3?,  and  the  antero-posterior  diameter 


UTERINE  NEOPLASMS—  M  1 V / MA. 


419 


2f.  Both  appendages  were  affected,  the  tubes  thickened  and  indurated,  the 
ovaries  cystic,  the  meso-salpinx  thickened,  and  the  pedicles  containing  an 
excess  of  fibrous  tissue.  The  bulk  of  the  tumour  was  composed  of  bundles 
of  plain  muscular  tissue,  interspeised  amongst  which  were  gland  tiibnles 
embedded  in  a  mass  of  richly  cytogenic  lymph  adenoid  connective  tissue. 
The  gland  tubules  were  composed  of  a  single  layer  of  columnar  epithelium 
Ijing  on  an  intact  basement  membrane,  and  also  some  small  cystic  spaces 
lined  by  flattened  epithelium,  similar  to  the  gland  tubules  of  the  endo- 
metiium.  There  were  no  cilia.  The  stroma  exactly  resembled  the  endo- 
metrium. Strands  of  gland  tubules  continuous  with  the  interglandular 
stroma  of  the  endometrium,  containing  lymph  adenoid  stroma,  dipped  do\vn 
from  the  endometrium  amongst  and  between  the  muscular  bundles  of  the 
tumour,  and  the  gland  tubules  were  present  up  to  within  one-third  of  an 
inch  from  the  serous  covering  of  the 
uterus.  The  authors  say  with  regard 
to  the  derivation  of  adeno-myomata 
from  the  Wolffian  or  the  Miillerian 
ducts,  that  the  former  are  sub-peri- 
toneal and  dorsal,  and  the  latter  intro- 


a-f^?^E^"^^^S?S3g^-' 


W:'/j^:^^;:i;^=i:^^::^v-::-A:g^^M 


Figs.  285.  286.— UxEraxE  Ai.Ex.orA.     (MrRDOCH  Camekox  am.  F.  E.  Taylor.) 

mural  or  sub-mucous,  and  frequently  ventral.  They  refer  to  the  '  rest  cells ' 
derived  from  the  Wolffian  ducts,  which  Von  Eecklinghausen  believed  to  be 
the  origin  of  the  adeno-myomata.  Their  presence  in  the  Fallopian  tube, 
broad  ligament,  uterns,  or  vagina,  is  explained  by  the  course  of  tlie  "Wolffian 
ducts.  The  relative  proportions  of  glandular  and  muscular  elements  will 
determine  the  hardness  or  softness  of  the  tumour,  and  if  the  gland  tubules 
be  dilated  and  contain  fluid,  a  cyst-adenoma  will  be  formed.  Hence, 
Von  Recklinghausen's  classification  into  hard,  soft,  softest,  or  telangiectatic 
and  cystic,  the  sub-peritoneal  tumours  being  harder  than  the  intramural, 
and  the  commonest  site  the  tubal  angle.  They  are  devoid  of  a  regular 
capsule,  and  hence  there  is  no  sharp  differentiation  from  surrounding 
stnictures.  The  authors  agree  with  Cullen  that,  quite  independently  of  the 
Wolffian  origm,  the  adenomata  arise  from  the  mucous  membrane,  and  these 


420  DISEASES   OF    WOMEN. 


tumours  have  a  central  situation.  The  adenoma  which  arises  from  the 
uterine  glands  is  a  rare  form.  As  regards  the  peritoneal  origin  of  the  growth, 
the  authors  ask  if  it  be  not  possible  for  the  peritoneum  covering  the  uterus 
to  be  modified,  and  having  dipped  mto  its  substance,  to  form  adenomata  by 
proliferation.  Eschoff  considered  that  the  peritoneum  covering  a  myomata 
might  dip  into  it  and  be  thus  cut  off,  in  a  manner  precisely  similar  to  the 
canaliciila  of  the  mucous  membrane. 

Dangers  to  Life  arising  from  Uterine  Myomata. — The  dangers 
to  life  arising  from  uterine  myomata  may  be  considered  under  these 
heads  : — those  which  arise  from  extra-uterine  complications,  pelvic 
and  other,  and  which  are  co-existent  with  the  tumour  ;  degenerative 
in  the  tumour  itself ;  circulatory  complications  ;  mental  effects  j 
general  consequences.  To  these  we  may  add  such  accidental  con- 
ditions as  torsion  of  an  ovarian  pedicle,  appendicitis,  hernia  (umbilical 
and  other),  and  carcinoma  of  the  cervix  independent  of  the  myoma. 

The  more  serious,  as  they  are  the  more  common,  of  the  first  class 
are  the  complications  due  to  diseased  states  of  the  adnexa.  Here 
we  have  not  only  the  consequences  arising  from  the  presence  of  the 
tumour  itself,  but  the  associated  risks  which  are  super-added  by 
the  ovarian  or  tubal  disease  which  is  attendant,  and  which  has 
to  be  considered,  not  merely  from  its  direct  effects,  but  also  from 
the  influence  it  may  exert  on  subsequent  operative  steps  for  removal 
of  the  myoma,  through  the  formation  of  serous  adhesions,  the  presence 
of  pus  in  the  pelvis,  and  the  added  difficulty  of  preventing  bowel 
and  septic  complications.  With  regard  to  the  bowel,  in  the  days 
when  the  radical  treatment  of  myoma  was  seldom  thought  of,  and 
pressure  on  the  bowel  with  the  growing  myoma  in  the  pelvis 
frequently  occurred,  obstruction  was  no  uncommon  consequence  as 
the  growth  of  the  myoma  increased.  And  it  is  still  one  of  those 
complications  which  compel  interference.  The  frequent  occurrence 
of  omental  and  intestinal  adhesions  is  known  to  every  surgeon, 
and  the  unpleasant  abdominal  accompaniments  of  the  myoma  as  it 
rises  from  the  pelvis  (such  as  pain  and  sickness,  with  flatulent 
distension),  are  the  results.  Both  peritonitis  and  ascites  are  also 
frequent  attendants  on  myoma.  I  recently  operated  on  a  patient, 
aged  50,  who  had  a  large  myoma  which  for  years  had  given  no 
distress,  when  suddenly  she  had  an  attack  of  acute  peritonitis, 
followed  soon  after  by  another,  so  severe  that  it  forced  on  the 
operation.  Such  attacks  of  peritonitis  bring  about  an  accumu- 
lation of  fluid  in  the  peritoneum,  and  the  resulting  ascites  likewise 
demands    hysterectomy.     They  are    to   be   expected    after   sudden 


UIERLSL:  SKUPLA.iMS—M VuMA.  I2l 


stretching  of  the  peritoneum,  subacute  attacks  of  inHainmation 
in  the  capsule  of  the  tumour  itself,  rotations  and  subsequent 
torsion,  associated  adnexal  disease,  or  secondary  degenerations  in 
the  myoma.  Of  the  urinary  complications,  the  most  serious  are 
the  secondary  renal  changes  caused  by  pressure  on  the  pelvic  \essels 
and  the  ureter.  In  these  the  presence  of  albumen  is  an  eaaJy 
evidence  of  the  renal  mischief.  Various  bladder  troubles,  such  as 
frequency  of  or  difficulty  in  the  passing  of  urine,  distension  of  the 
bladder,  and  the  tendency  to  post-operative  cystitis,  are  commonly 
met  with.  The  imprudence  of  delaying  operation  until  interference 
with  the  ureter  results  in  hydronephrosis  or  pyo-nephrosis,  is  obvious. 
Mason  Knox  noted,  among  the  complications  of  myoma  out  of 
twenty-two  cases  collected  by  him,  these  consequences  :  (1)  ureteral 
pressure  at  the  pelvic  Ijrim  ;  (2)  ureter  lifted  up  by  the  under- 
lying tumours ;  (3)  ureter  adherent  over  a  considerable  surface  of 
the  tumour ;  (-t)  ureter  surrounded  by  the  tumour  ;  and,  as  more 
important,  pyelonephrosis  and  pyoureter. 

"We  now  come  to  a  complication  which  is  probably  that  which 
most  frequently  compels  operation — namely,  hemorrhage.  Fol- 
lowing in  its  wake  are  anaemia  and  cardiac  affections.  The  pro- 
foundly amemic  state  which  we  see  as  a  result  of  the  constant  or 
recurring  bleeding  is  associated  with  rhythmic  irregularity,  inefficient 
action  or  dilatation  of  the  heart.  The  compensative  hypertrophy, 
which  is  found  in  some  cases  of  myoma,  loses  its  value  in  face  of  the 
continued  depletion  and  spanaemic  state  of  the  blood.  How  unfor- 
tunate it  is  to  be  compelled  to  subject  a  patient  under  these 
conditions  to  the  effects  of  a  prolonged  operation,  involving  con- 
siderable, if  not  profound,  shock,  it  is  not  necessary  to  say. 
The  next  class  is  one  which  has  to  be  dealt  with  fully,  as  the 
occurrence  of  pregnancy  with  myoma  is  one  of  the  most  serious  com- 
plications of  the  former.  In  a  previous  chapter  I  have  entered 
fully  into  the  disorders  of  mentalization  which  follow  affections  of 
the  genitalia,  foremost  amongst  which  is  tumour  of  the  uterus. 

Apart  from  all  these  diseased  correlations  of  myoma,  there  are 
others  which  I  have  included  under  '  general  consequences.'  These 
are  mainly  deterioration  in  health  generally,  from  pain,  want  of 
exercise,  the  sense  of  weight  in  the  abdomen,  constipation  and 
urinary  disturbance,  and  the  depressing  effect  associated  occasionally 
with  insomnia.  Cardiac  rhythmic  disturbance  and  hypertrophic 
valvular  degenerations  are  frequently  found  in  the  instances  of 
women  who  have  suffered  from  a  bleeding  myoma,  and,  indeed,  in 


422  DISEASES   OF    WOMEN. 

other  cases  ia  which  hemorrhage  is  not  a  prominent  sign.  Add  to 
these  the  possible  presence  of  those  accidental  conditions  referred  to, 
and  we  must  acknowledge,  without  any  desire  to  exaggerate,  or  to 
accentuate  the  evils  that  may  attend  upon  the  presence  of  a  myoma, 
that  the  complications  which  are  found  in  its  train  are  sufficiently 
grave  to  make  the  surgeon  hesitate,  or  at  least  to  consider  carefully, 
before  he  decides  to  adopt  tentative  or  palliatiye  measures,  even  in 
a  case  in  which  no  degenerative  changes  are  suspected  in  the  tumour 
itself. 

Adhesions. 

Perhaps  not  the  least  serious  of  the  complications  which  have  to 
be  considered,  in  connection  with  the  growth  and  the  age  of  a 
myoma,  are  the  adhesions,  pelvic  and  extra-pelvic,  which  are  liable 
to  be  formed  between  the  tumour,  the  omentum,  the  intestine,  the 
bladder,  and  the  rectum.  For  not  only  have  we  to  remember  the 
direct  effects  of  such  adhesions  on  the  viscera  which  are  involved, 
but  also  the  increase  of  the  difficulties  which  have  to  be  overcome  at 
the  time  of  operation,  and  the  necessary  prolongation  of  this  in  the 
management  of  the  adhesions,  or  the  complications  and  accidents 
they  cause  at  the  time,  through  the  implication  of  the  bowel,  bladder, 
and  ureters  entailed  by  their  separation,  not  to  speak  of  haemorrhage. 
Such  occurrences  as  inversion  of  the  uterus,  and  actual  rotation  of  the 
tumour,  are  not  to  be  forgotten,  though  they  are  very  rare. 


Adnexal  Complications. 

That  the  proportion  of  cases  in  which  inflammatory,  suppurative, 
cystic,  and  various  degenerative  changes,  as  well  as  neoplasms  of 
either  the  ovaries  or  Fallopian  tubes,-  or  both,  complicate  myomatous 
tumours  of  the  uterus,  is  considerable,  cannot  be  gainsaid,  and  these 
may  of  themselves  demand  interference,  independently  of  any  ques- 
tion of  expediency  with  regard  to  removal  of  the  uterus.  It  may  be  a 
matter  for  discussion  whether  salpingo-oophorectomy  alone,  without 
interference  with  the  uterus,  or  combined  with  either  supravaginal 
hysterectomy  or  hysterectomy,  should  be  performed.  If  both  adnexa 
be  diseased  to  such  an  extent  as  to  necessitate  their  removal,  then  it 
will  be  a  question  as  between  the  supravaginal  operation  or  that  of 
pan-hysterectomy.  Should  those  of  only  one  side  be  so  involved,  and 
myomectomy  can  be  performed,  then  there  would  be  no  justification 
for  removal  of  the  uterus. 


UTERINE  NEOPLASMS— MYOMA.  423 

Adnezal  Tumours  and  Myoma — Oophorectomy. — An  interesting  case  bearing 
on  this  question  came  iukKt  olisorvatioii  a  few  years  since.  Tlie  patient, 
a't.  42,  who  had  been  seen  by  many  gyncTCologists,  had  suffered  for  some 
years  from  severe  menorrhagia  and  metrorrhagia,  with  associated  anajmia 
and  consequent  cardiac  distress.  She  had  had  attacks  of  severe  pelvic  peri- 
tonitis, and  there  was  more  or  less  constant  pain  in  the  region  of  the  ovaries. 
On  examination,  these  latter  were  found  enlarged  and  adherent.  The  utenis 
was  about  the  size  of  the  closed  fist,  and  wth  a  fibroid  projection  in  the 
anterior  wall.  This  explained  the  bladder  imtation  from  w^hich  she  suffered. 
I  advised  salpingo-oophorectomy.  I  had  not  raised  the  question  of  hysterec- 
tomy. The  operation  was  difficult  and  tedious,  from  the  mass  of  adhesions  in 
which  the  adnexa  at  both  sides  were  embedded.  These  had  literally  to  be 
"  dug  out "'  of  the  bed  m  which  they  lay  concealed.  On  bringing  the  uteiiis 
forwards,  the  fundus  was  found  to  be  studded  all  over  Avith  fibroraatous  pro- 
jections, giving  it  a  nodulated  appearance,  the  principal  nucleus  being  in  the 
anterior  wall.  The  operation  was  performed  in  189(5.  Since  then  there  have 
been  no  pelvic  symptoms  whatever,  and  when  I  last  examined  the  utenis  it 
was  considerably  reduced  in  size. 

(1)  Adhesions   between  the  Tumour   and   the   Genito-urinary 
Organs — (2)  Infections  of  the  Urinary  Tract.— Though  the  symptoms 


Fig.  287. — Pteloxephbosis  and  Ptouketei;. 
The  result  of  compression  by  a  myomatous  tumour  at  the  pelvic  brim  (6  lbs.). 
The  case  was  complicated  by  an  appendical  adhesion  to  the  wall  of  the 
right  ureter,  above  the  constriction.     Tumour  removed  by  Howard  Kelly, 
and  one  month  later  the  kidney  and  portion  of  ureter  by  :McCoy.* 

of  iireteral  pressure  are  often  negative,  albumen  and  casts  were  noted 

several  times,  also  pus  and  persistent  pyurea,  difficulty  of  micturition 

*  Mason  Kuux,  Amer.  Jour.  Obslet.,  vol.  xlii.,  190U. 


424  DISEASES   OF    WOMEN. 

and  retention  of  urine,  while  death  from  uraemia  occurred  in  three 
cases,  and  post-operative  anuria  in  two,  from  nerve  shock  to  the 
kidney  after  relief  from  the  ureteral  pressure.  Eetention  of  urine, 
severe  pain  in  the  side,  in  the  renal  region,  or,  in  more  extreme 
cases,  the  detection  of  a  fluctuating  tumour  of  varying  extent  in  the 
lumbar  region,  are  important  signs  and  symptoms  in  diagnosis.  The 
catheterization  of  the  ureters  by  means  of  the  cystoscope  will  deter- 
mine the  site  of  the  constriction ;  a  wax  tip  on  the  end  of  the 
catheter,  the  presence  of  a  calculus ;  and  the  examination  of  the 
urine  which  is  drawn  off,  the  condition  of  the  kidney. 


CHAPTER  XXir. 

UTERINE  NEOPLASMS-  MYOMA  (continued). 

DiflFerential  Diagnosis  and  Palliative  Treatment. 

Diagnosis. 

We  distinguish  a  fibroid  tumour  of  the  body  of  the  uterus  by — 

The  history  of  the  case. 

Careful  examination  of  the  abdomen  (see  '  Examination  of  a  Case  ' 

and  '  Methods  of  Examination'), 
Digital  and  bimanual  examination  (rectal  and  vaginal). 
The  uterine  sound. 

The  diagnosis  of  some  fibroid  tumours  of  the  uterus  is  not  always  so  easy  a 
matter  as  it  may  appear.  "When  a  student,  I  saw  an  excellent  surgeon,  after 
the  preliminary  incision  for  ovariotomy,  vainly  endeavom'ing  to  push  a  trocar 
into  a  solid  fibroid  of  the  uterus.  Several  experienced  physicians  and 
surgeons  had  concurred  in  the  diagnosis.  By  that  lesson  (the  woman  died 
the  same  day)  I  was  early  taught  the  need  for  that  extreme  caution  which 
we  must  exercise  in  ambiguous  cases  before  we  arrive  at  a  conclusion,  or 
pronounce  an  opinion.  The  old  dictum,  '  Verify,  verify,  and  for  a  third 
time  verify,'  is  not  more  truly  applicable  to  anything  than  to  the  case  of 
abdominal  tumours.  While  exercising  aU  the  care  and  caution  that  he 
possibly  can,  the  surgeon  may  fall  into  error  in  some  cases.  Spencer  Wells 
said  :  '  In  fact,  it  has  happened  to  many  surgeons,  and  to '  myself  amongst 
the  number,  that  we  have  commenced  operations,  as  ovariotomy,  and  even, 
removed  tumours  from  the  abdomen,  under  the  impression  that  we  were 
dealing  with  diseased  ovaries,  when,  upon  examination,  they  have  proved  to 
be  pedunculated  fibroid  outgrowths  from  the  uterus.' 

At  a  meeting  of  the  Gynaecological  Society  (June  23,  1886),  Lawson  Tait 
exhibited  '  a  huge  suppurating  cyst,  consisting  of  the  dilated  structure  of  the 
left  kidney.  The  patient  had  been  seen  previously  by  Sir  Spencer  Wells, 
who  had  diagnosed  fibroid  tumour  of  the  uterus,  and  by  a  distinguished 
London  physician,  who  remarked  that  he  did  not  think  there  was  anything 
very  much  the  matter.  Dr.  Milner  Moore  of  Coventry  was  called  in,  and 
diagnosed  a  suppurating  ovarian  tumour.  Tait  saw  the  patient  and  confirmed 
this  view,  believing  that  the  suppuration  was  due  to  strangidation  and  axial 


426 


DISEASES   OF    WOMEN. 


rotation.     All'tlie  opinions  proved  to  be  wrong,  for  the  tumour  turned  out  at 
operation  to  be  the  left  Iddney.'     The  patient  made  an  admirable  recovery  ! 

History  of  the  Case. — Three  negative  points  are  of  importance  : 
that  the  tumour  has  not  appeared  suddenly ;  that  there  have  been 

no    symptoms     in     the 


early  history  of  the 
case  of  a  febrile  state  ; 
rarely  is  there  any  his- 
tory of  an  injury.  There 
has  commonly  been 
haemorrhage,  both  mo- 
norrhagia and  metror- 
rhagia. This  latter 
symptom  varies  in  de- 
gree. Occasionally  the 
menstrual  periods  are 
irregular,  and  the  dis- 
charge scanty.  There 
may  have  been  pelvic 
distress,  and  some  trou- 
ble of  the  bladder  and 
rectum.  These  pelvic 
symptoms  depend  on  the 
position  of  the  tumour, 
its  size,  and  the  rapidity 
of  its  growth.  This  is 
generally  slower  than  in 
ovarian  cystoma.  There 
is  not  the  same  rapid 
emaciation  of  the  coun- 
tenance which  we  see 
so  commonly  in  ovarian 
disease.  Many  women 
who  have  large  uterine 
fibroids  do  not  exhibit 
any  marked  change  in 
the  expression  of  the 
face,  nor  is  the  fibroid 
affection  accompanied 
by  the  same  pallor  of 
the    countenance,    unless    there    be   heemorrhage,    that   marks   the 


Fig.  288.  —  A  Pedt:ncxilated  Subperitoneal 
Fibroid,  with  Multiple  Nuclei  springing 
FROM  THE  Fundus  Uteri.     (Author.) 


Fig.  289. — Retroversion  of  a  Fibromatous 
Uterus.    (Doyen.) 


> 

X 

X 


< 


2   - 


2:    ? 
■31  ^ 


PLATE   XXXVIII. 


Uteeixe  Myoma  with  E3ibedded  Multiple  Nuclei  removed  at^^the 
Climacteric  by  Supea-vagixal  Hysterectomy.     (Author.) 

[To  face  p.  4:27. 


UTERINE  NEOPLASMS— M YOMA. 


427 


growth  of  the  ovarian  cyst.  The  presence  or  absence  of  pain  will  in 
great  measure  depend  on  the  position  of  the  tumour,  whether  it  be 
pediculated,  and  the  direction  in  which  it  grows.  Periodical 
attacks  of  peritonitis,  interference  with  the  functions  of  the  bladder 


Fig.    290.  —  Fibromtoma,    spsixgixg 
FROM  THE  Ligament  of  the  Ovaet. 

(DOLEEIS.) 


Fig.    291.  —  Pediculated    Fibeoma 

OF  UtEEUS,  "WITH  FrBBO-CTSTIC  Ix- 
TEEIOK  I-V  OsE  DiVISIOX.  (i^CHECE- 
DER.) 


or  rectum,  and  inflammatory  changes  in  the  txmiour  itself,  will  give 
rise  to  pain.  Recurrent  attacks  of  acute  pain  are  indications  of 
some  axial  rotation  and  twisting  of  the  pedicle.  We  often,  how- 
ever, see  large  uterine  fibroids,  the  growth  of  which  has  not  been 
attended  by  pain. 


Differential  Signs  (Positive)  of  Fibromyomatous  Tumour. 

Enlargement  of  the  low-er  portion  of  abdomen. 

Enlargement  of  the  superficial  abdominal  veins. 

On  palpation  we  find  a  solid,   symmetrical,    and    fixed    tumour, 

though  this  will  depend  on  the  natui'e,  .shape,  attachment,  and 

the  direction  of  growth  as  well  as  the  adnexal  complications  of 

the  tumour. 
Tumour  usually  central ;  the  increase  in  abdominal  measurement 

is  most  marked  from  the  pubes  to  the  umbilicus. 


428  DISEASES   OF   WOMEN. 

The  uterine  enlargement,  even  early  in  the  disease,  may  be 
defined  by  palpation  and  percussion  over  the  pubes.  Vascular 
mui'murs  are  frequently  heard  synchronous  with  the  pulse. 

Sy  such  an  examination,  the  uterus  is  found  enlarged,  either  in  its 
anterior  or  posterior  wall.  The  extreme  hardness  may  be  at 
once  apparent  to  the  finger,  or  we  may  find  two  or  three  nodular 
enlargements;  or  the  entire  uterus  may  feel  like  a  hard, 
immovable  mass,  fixed  in  the  pelvis. 

Adherent  Adnexal  Masses. — The  condition  which,  in  a  superficial  examina- 
tion, is  most  liable  to  be  mistaken  for  a  myomatous  mass,  is  an  old  and  hard 
infiltration  in  the  pelvis,  in  which  the  ovaries  and  tubes  are  involved,  they 
themselves  being  possibly  firmly  embedded  in  the  exudation,  adherent  to  the 
uterus,  and  probably  also  to  the  bowel  and  surrounding  pelvic  structures.  It 
is  almost  impossible,  save  under  a  most  careful  bimanual  examination  under 
an  anaesthetic  (and  even  here  it  is  difficult),  to  difierentiate  between  a  myoma 
and  a  parametric  exudation  with  pus  tubes  and  adherent  ovaries.  Two  cases 
recently  seen  by  me  will  exemplify  this  difificnlty.  In  one,  a  patient  had  had 
a  pessary  applied  for  a  retroflexed  uterus.  After  a  time  another  gynaecologist 
diagnosed  a  myoma.  A  third,  seeing  her  shortly  afterwards,  considered  the 
case  to  be  one  of  inoperable  carcinoma.  I  saw  her,  and  at  the  first  examina- 
tion (without  anaesthesia)  concurred  in  the  view  that  it  was  a  myoma. 
Advising  operation,  I  learned  afterwards  that  the  case  was  one  of  old  pyo- 
salpinx,  with  a  hard  infiltration  incorporating  it  with  an  enlarged  uterus. 

In  the  other  instance,  there  was  a  difference  of  opinion  as  to  myoma  or 
adnexal  tumour.  At  operation  a  hard  infiltration  extended  across  the  entire 
pelvis,  involving  both  tubes  and  ovaries ;  and  another  dense  mass,  firmly 
attached  to  the  uterus,  over  its  posterior  wall,  contained  a  portion  of  the 
rectum,  which  tunnelled  its  centre.  Where  the  adnexal  masses  are  attached 
bi-laterally  to  the  cornua  of  the  uterus,  and  thus  appear  continuous  with  its 
walls,  they  closely  resemble  myomata. 

The  OS  uteri  is  generally  healthy,  at  times  depressed  ;  but  more 
frequently,  in  advanced  fibroid  tumour,  it  has  receded,  and 
may  not  be  reached  by  the  examining  finger. 

There  is  occasionally  a  characteristic  hardness  of  the  cervix, 
which  may  be  felt,  like  the  nipple  of  the  breast,  moving  over 
the  growth  underneath.  This  mobility  of  the  conical  cervix, 
independent  of  the  enlarged  body,  is  very  marked  in  many  cases 
of  fibroid  tumour. 

The  rectal  and  recto-vaginal  examinations  discover  the  enlarged, 
fixed,  and  hardened  uterus. 

The  only  method,  however,  of  preventing  an  error  is  by  making  a 
careful  bimanual  examination  in  the  dorsal  position.      In  certain 


UTEliJSE   XEOPLA  NJ/S— .1/  ] 'OMA .  429 

cases  even  this  is  unreliable,  unless  we  resort  to  antesthesia  and 
verify  by  the  sound. 

Negative  Signs. 

There    is    not    (generally)    any    fulness    or    prominence    of    the 

umbilicus. 
There  is  not  (save  in  fibro-cystic  disease),  unless  there  be  ascitic 

fluid  present,   any  fluctuation.     Should   there    be,    it    is    very 

different  from  the  superficial  wave  seen  in  ovarian  disease. 
(When  there  is  a  hard  pelvic  tumour,  and  at  the  same  time 

evidence  of  the  presence  of  fluid,  we  suspect  the  fluid  to  be 

ascitic.) 
There  are  no  uterine  contractions. 
The  characteristic  signs  of  pregnancy  are  absent, 

Jones  *  lias  drawn  attention  to  a  condition  of  the  pregnant  uterus  which 
may  be  mistaken  for  a  fibroid  tumour,  in  which  the  characteristic  feel  of  the 
former  is  absent,  as  also  the  pear-shape  of  pregnancy,  there  being  a  false 
sensation  of  the  presence  of  a  pedicle.  He  attributed  it  to  an  absence  of  the 
amniotic  fluid.  Pozzi  ascribes  it  rather  to  a  pre-existing  condition  of  hyper- 
trophy or  elongation  of  the  neck  of  the  uterus. 

The  Uterine  Sound. — "We  thus  see  that  in  a  considerable  pro- 
portion of  cases  we  may  feel  satisfied  of  the  nature  of  the  tumour 
without  the  use  of  the  uterine  sound.  But  this  mode  of  examina- 
tion is  absolutely  necessary  to  confirm  the  diagnosis  in  some  cases. 
By  it  we  learn  (utero-abdominal,  utero-vaginal,  and  utero-rectal 
methods)  — 

(«)  The  degree  to  which  the  uterus  is  enlarged ; 

(h)  That  the  tumour  felt  through  the  abdominal  wall  is  an 
enlarged  uterus ; 

(c)  That  the  tumour  is  fixed  or  movable ; 

(d)  To  differentiate  fibroid  tumours  from  other  pelvic  enlargements 

or  flexions  of  the  uterus. 

Dilatation  by  Tents  and  Exploration. — In  some  cases,  when  still  in  doubt, 
we  may  have  to  dilate  the  uterus  and  explore  the  cavity  with  the  finger. 

In  a  case  of  supposed  blighted  ovum,  SchroBder  dilated  the  uterine  canal, 
and  the  tumour  was  discovered  to  be  a  hard  fibroid.  The  same  step  may  be 
needed  in  chronic  hyperplasia.  In  the  diagnosis  of  fibroid  of  the  fundus  or 
submucous  pediculated  tumours,  dilatation  and  exploration  with  the  finger 
are  necessary,  in  order  to  discover  such  growths. 

*  Edinburgh  Medical  Journal,  March,  1888. 


480 


DISEASES   OF   WOMEN. 


Symptoms. — Uterine  fibroids  frequently  exist,  and  yet  there  are 
no  symptoms  to  attract  attention  during  life.  Their  presence 
is  only  discovered  in  a  post-mortem  examination.  The  most 
important  symptom,  as  it  is  generally  the  earliest,  is  monorrhagia. 
This  comes  on  gradually,  at  first  as  an  increase  of  the  menstrual 
period,  amounting,    after   a    time,  to    flooding,  or    there    may    be 


Fig.  292. — Lakge  Uterine  FrBEoiD  with  Extensive  Subpekitoneal  Rela- 
tions FILLING  the  Pelvis  and  Abdominal  Catity;  Adnexa  on  the 
Summit  of  the  Tumour.     (Howard  Kelly.) 

irregular  haemorrhages.  The  loss  of  blood  may  threaten  the  life  of 
the  patient.  Death  has  followed  from  a  rupture  of  a  uterine  sinus. 
Large  vessels  do  not  generally  enter  a  uterine  fibroid,  or  only  such 
as  have  no  capsule.  The  blood  is  poured  out  by  the  congested 
mucous  membrane  of  the  uterus.  Cervical  fibroids  do  not,  as  a  rule, 
cause  haemorrhage. 

Pain. — This  assumes,  in  some  instances,  the  form  of  dysmenorrhcea, 
especially  in  the  case  of  the  cervical  fibroid.  Pain  also  occurs  from 
the  weight  and  distension,  and  the  pressure  of  the  tumour  on  the 
viscera  and  nerves  of  the  pelvis.  It  is  frequently  of  a  '  bearing- 
down'  nature.  It  accompanies  slight  attacks  of  peritonitis  as  the 
tumour  grows  or  shifts  its  position.  It  is  preseiit  when  there  is  any 
axial  rotation  of  the  pedicle. 

Pelvic  Symptoms. — Pressure  on  the  bladder,  rectum,  and  ureters 
produces  frequent  and  painful  micturition,  constipation,  and  pain 


UTERTXE   NEOPLASMS— M  YOMA.  431 


iu  dffa'cation.  It  may  leul  to  hydro- nephrosis,  or  albuminuria,  with 
uneniic  symptoms.  The  consequences  that  may  arise  from  com- 
pression of  the  ureters  have  to  be  kept  in  mind  in  cases  of  growing 
or  hirge  fibromata,  and  will  naturally  suggest  that  the  urine  in  these 
cases  should  be  from  time  to  time  examined,  not  alone  for  the 
presence  of  albumen  or  hyaline  casts,  but  also  for  an  increase  in  the 
quantity  of  urea. 

Sterility. — This  is  a  common  consequence  of  uterine  fibroid 
symptoms  arising  from  the  presence  of  pregnancy.  Fibroid  tumours 
may  induce  abortion,  seriously  complicate  labour,  and  cause  post- 
partum haemorrhage. 

Some  Terminations  of  Fibromyoma. 

1.  Arrest  of  Development. — It  may  thus  interfere  but  little  with 
the  health  or  comforb  of  the  individual. 

2.  Spontaneous  Absorption. — This  is  extremely  rare. 

3.  Spontaneous  Enucleation, — The  tumour  is  protruded  through 
the  lacerated  or  sloughing  mucous  membrane.  It  is  thus  uncovered, 
and  is  forced  onwards  into  the  vagina  by  the  uterine  contraction. 

4.  The  tumour  becomes  pediculated,  and  is  extruded  into  the 
vagina  in  the  form  of  a  polypus ;  or,  if  subperitoneal,  becomes 
adherent,  and  remains  either  attached  to  some  organ  or  lies  loose  in 
the  peritoneal  cavity. 

5  Suppuration  and  Gangrene. — This  may  lead  to  perforation  of 
the  other  viscera,  peritonitis,  and  septicfemia.  The  fibromyoma  may 
thus  be  disintegrated  and  discharged  in  fragments. 

6.  Degenerations. — The  various  forms  of  degeneration  already 
enumerated. 

7.  Adhesions. — Adhesions  form  between  the  tumour  and  any  of 
the  neighbouring  viscera,  more  particularly  the  omentum,  intestine, 
bladder,  and  rectum.  Such  adhesions  cause  hepatic,  renal,  and 
pehdc  complications. 

8.  Inversion  of  the  Uterus. — It  is  well  to  recollect  that  those 
fibroid  tumours  having  a  broad  base,  and  which  are  connected  with 
the  parenchyma  of  the  fundus,  may  cause,  in  their  growth  and 
extrusion,  partial  inversion  of  the  uterus. 


432  DISEASES   OF    WOMEN. 


Fibro-Cystic  Tumours.* 

Differentiation. — I  hardly  know  &nj  affection  in  the  diagnosis  of  which  the 
practitioner  is  more  likely  to  fall  into  error,  than  in  that  of  a  large  fibro-cyst 
of  the  uterus.  I  can  recall  to  mind  a  few  cases  myself,  in  -which,  notwith- 
standing repeated  and  most  exhaustive  examinations,  I  have  been  mistaken. 
Still,  this  liability  to  err  is,  with  our  improved  knoAvIedge,  becoming  less  each 
day.  If  the  practitioner  be.  resolved  to  take  nothing  for  granted  in  the 
examination  of  a  patient,  and  pass  step  by  step  by  a  process  of  exclusion  to 
his  final  judgment,  he  will  not  be  likely  to  make  any  mistake.  Let  us  suppose 
that  he  has  to  distinguish  in  a  given  case  hetiveen  ovarian  itimotir,  jjregnancy, 
and  afihro-cyst  of  the  uterus.  He  must,  in  deciding  the  question  of  fibro-cyst, 
side  by  side  with  the  other  two  conditions,  fibro-cyst  or  ovarian  tumour,  be 
influenced  by  these  clinical  facts. 

1.  The  length  of  time  the  tumour  has  taken  to  grow,  and  its  mode  of 

growth. 

2.  In  palpation,  the  irregularity  or  dense  feel  of  the  tumour  in  parts. 

3.  The  obscure  character  of  the  fluctuation  as  compared  with  ovarian  dropsy. 

4.  The  exclusion  of  the  signs  and  symjptoms  of  pregnancy. 

5.  The  depth  to  which  the  uterine  sound  passes. 

6.  The  mobility  of  the  tumour  with  the  uterus,  both  with  the  uterine  sound 

and  bimanually. 

7.  A  careful  examination  by  the  rectum  and  vagina  of  the  tumour  under 
an  aniBsthetic,  in  the  bimanual  method. 

8.  Aspiration  and  examination  of  the  fluid. 

(a)  Its  property  of  coagulating,  spontaneously  and  by  heat. 

(b)  The  presence  of  Atlee's  fibre-cell. 

9.  By  an  exploratory  incision  :  the  colour  of  the  uterine  wall  (dark  red)  is 
characteristic  and  quite  distinct  from  the  appearance  of  the  cyst  wall  of  the 
ovarian  cystoma." 

(See  chapter  on  Diagnosis  of  Ovarian  Tumours.) 

Palliative  Treatment  of  Uterine  Tumours.— T/te  Palliative  and 
Expectant  Method  consists  in  the  use  of  means  calculated — 

1.  To  reduce  hypersemia  and  congestion. 

2.  To  control  and  prevent  haemorrhage. 

3.  To  promote  absorption  of  the  tunaour. 

4.  To  subdu^e  pain  and  relieve  rectal  and  vesical  distress,    and 

reduce  hypera?mia  and  congestion. 

To  reduce  Hyperaemia  and  Congestion.  Internally,  for  this 
object- we  give  such  medicines  as  ergot  (liquid  extract)  ;  hydrastis  ; 
stypticine  ;  digitalis  ;  iodide  of  potassium  ;  bromides  of  sodium  and 
potassium  ;  chloride  of  calcium  ;  a  course  of  Woodhall  Spa,  Kreuz- 
nach,  or  Salsomaggiore  waters. 

*  See  p.  411  for  Etiology. 


rTER/XE  NEOPLAf^MS— MYOMA.  433 

Bedford  Brown  rejiorts  favourably  of  the  prolonged  use  of  Syrup  of  Lacto- 
phosphate  of  Lime  and  the  Syrup  of  the  TIypo|>hosphites,  given  in  3ii.  doses 
three  times  in  the  day.  In  anjemia  from  recurrent  luemorrhage  in  fibroids,  this 
combination  is  an  admirable  restorative  anil  tonic. 

Hydrastis  Canadensis. — My  success  with  hydrastis  in  fibroids  has  been 
uncertain.  I  have  given  it  in  a  number  of  cases,  both  as  tincture,  fluid,  and 
extract ;  also  hydrastia  and  hydrastinine.  A  useful  mixture  for  checking 
haemorrhage  is — 

R.  Acid  sclerotic,  gr.  iv. 
Tinct.  digitalis,  min.  Ixxx. 
Tinct.  hydrastis  Can.  3ss. 
Tinct.  matico,  |ss. 
Elix,  saccharin,  min.  xsx. 
Inf.  matico  ad  5viii. 

One-eighth  part  every  third  or  fourth  hour. 

The  liquid  extract  of  ergot  (Sss.)  or  ergole  may  be  substituted  for  the 
sclerotic  acid,  and  tincture  of  strophanthus  for  the  tincture  of  digitalis,  or  the 
strophanthus  may  be  given  in  combination  with  the  latter. 

I  have  previously  (p.  207)  entered  fully  into  the  therapeutical  uses  of 
hydrastis,  its  alkaloid  hydrastia,  and  stypticine.  Both  the  palatinoids  of 
sclerotic  acid  and  stypticine,  with  those  of  stropbanthus,  are  of  use  in  cases 
of  bleeding  fibroid. 

Locally,  we  may  apply  the  hot  vaginal  douche  ;  scarify  the  cervix; : 
use  astringent  tampons  of  tannic  acid  and  glycerine,  adrenalin,  and 
ichthyol. 

Sexual  intercourse  must  be  moderated,  and  especially  it  should 
be  avoided  about  the  menstrual  periods. 

To  control  Hsemorrhag'e.— The  subcutaneous  injection  of  ergotine, 
as  recommended  by  Hildebrandt,  is  occasionally  efficacious  in  con- 
trolling haemorrhage.  I  have  injected  as  much  as  15  grains  of 
Bonjean's  ergotine,  mixed  with  water  and  glycerine,  into  the 
gluteal  region ;  but  the  average  dose  is  3  to  5  grains.  The  sterilized 
needle  must  be  passed  deeply  into  the  muscle,  otherwise  we  are 
apt  to  cause  an  abscess.  Much  cannot  be  hoped  for  any  result 
further  than  the  control  of  the  haemorrhage.  The  action  on  the 
structure  of  the  tumour,  or  in  promoting  spontaneous  expulsion  of 
intra-uterine  fibromata,  has  been  unsatisfactory  even  after  some 
hundreds  of  injections.  Sclerotic  acid  and  stypticine  may  also  be 
used  subcutaneously.  The  solution  of  ergotine  should  be  made 
fresh.  Astringents  may  be  given  internally.  The  douche  of  hot 
water,  115"  to  120^  should  be  used  for  ten  to  fifteen  minutes  three 
times  in  the  day. 

Dilatation  of  the  Cervical  Canal  with  sponge  or  laminaria  tents  will 

2   F 


434  DISEASES  OF   WOMEN. 

be  found  a  valuable  means  of  temporarily  treating  hpemorrhage,  or, 
in  the  case  of  a  cervical  fibroid,  and  where  there  is  dysmenorrhoea, 
incision  of  the  cervix. 

To  promote  Absorption  of  the  Tumour. — Ergot,  ergole,  or  ergotine, 
in  the  manner  recommended,  especially  if  the  tumour  be  submucous 
or  interstitial,  and  not  very  hard,  may  be  tried  ;  also  perchloride  of 
mercury,  iodide  of  potassium,  iodine  baths,  or  the  spas  of  Woodhall, 
Kreuznach,  or  Salsomaggiore. 

Electrolysis  was  first  advised  by  Cutter.  He  passed  the  current 
through  the  tumour  by  two  strong  steel  electrodes,  inserted  at  either 
side  of  the  abdomen,  and  reported  an  arrest  in  the  growth  in  thirty- 
two  out  of  fifty  cases  treated  in  this  manner.  The  practice  is 
seldom  resorted  to. 

Electro-Caustic  Treatment. — The  name  of  Apostoli,  of  Paris,  has 
now  become  prominently  associated  with  the  electro-caustic  treatment 
of  uterine  fibromata.* 

To  relieve  Pain  and  Rectal  or  Vesical  Distress. — This  must  be 
subdued  by  bromides  and  sedatives.  The  tumour,  if  large  and 
pressing  on  the  pelvic  ^dscera,  should  be  pushed  up  out  of  the  true 
pelvis.  If  it  be  subperitoneal,  great  relief  may  follow  this  step. 
Special  attention  must  be  paid  to  the  bladder  and  rectum.  Any 
accumulation  in  the  latter  should  be  prevented.  The  occasional 
use  of  an  enema  will  be  indicated.  If  a  small  myoma  in  the  anterior 
wall  of  the  uterus  resting  on  the  neck  of  the  bladder  should  cause 
vesical  distress,  much  relief  may  be  aff'orded  by  the  adjustment  of 
a  comfortably  fitting  Galabin's  pessary.  This  raises  the  uterus  off 
the  bladder,  and  relieves  the  pressure.! 

*  See  Electro-therapeutics.  f  See  chapter  on  Displacements. 


CHAPTER   XXIII. 

UTERINE    NEOPLASMS— MYOMA  (continued). 

Pregnancy  complicating  Myoma — Differentiation — Diagnosis 
and  Treatment. 

Differentiation  and  Diagnosis. 

The  possibility  of  pregnancy  and  fibroma  of  the  uterus  coexisting 
must  not  be  forgotten,  especially  in  those  cases  in  which  we  are 
assured  of  a  rapid  growth  of  the  tumour.  We  must  not  be  misled 
by  the  fact  that  the  catamenia  have  appeared.  "We  may  be  con- 
fronted with  a  case  in  which  the  existence  of  pregnancy  is  not 
suspected,  the  presence  of  a  tumour  alone  being  recognized ;  or  one 
in  which  the  woman  has  been  ignorant  of  the  presence  of  a  tumour, 
and  attributes  her  symptoms  to  pregnancy.  Or,  again,  we  may  be 
called  to  a  case  in  which,  though  cognisant  of  the  presence  of  a 
tumour,  she  fancies  (through  the  cessation  of  the  menstrual  act) 
that  she  has  become  pregnant.  In  any  suspicious  case  careful  regard 
must  be  paid  to  all  the  signs  and  symptoms,  positive  and  negative, 
of  the  existence  of  pregnancy.  She  should  be  examined  under 
anaesthesia,  and,  if  a  diagnosis  cannot  be  arrived  at,  periodical 
examination  should  be  made  to  estimate  the  growth  of  the  tumour, 
determine  the  presence  or  absence  of  the  signs  of  pregnancy,  and 
the  condition  of  the  patient. 

Errors  in  Diagnosis. — It  has  to  be  remembered  that  serious 
errors  of  diagnosis  have  been  made  with  regard  to  fibroma  and 
pregnancy.  The  uterine  pains  due  to  the  tumour,  when  there  has 
been  effacement  of  the  cervix,  have  been  mistaken  for  those  of 
labour,  as  pointed  out  by  Puech,'-  and  a  rapid  maternal  pulse  for 
the  foetal  pulsations. 

*  Archives  de  Gynaecol.,  vol.  sxii.,  Nov.  11,  1895 ;  Gaz.  des  Eopitaux,  Aug., 
1895;  and  Brit.  Gyn.  Journ.,  pp.  44-40,  1896  (Haultain — Cases  of  Myoma 
complicatiug  Pregnancy — ibid.'). 


436 


DISEASES   OF   WOMEN. 


The  prominences  occasioned  by  the   foetal  members  disappear  when  the 
uterus  contracts,  while  those   of  fibromata  are  made  more  manifest.     The 


same  author  quotes  instances  in  wliich  fibroma  has' been  mistaken  for  ovarian 
cystoma  at  the  time   of  labour,  and  vice  versa.     Many  most  distinguished 


UTERINE  NEOPLASMS—.UrO.WA    AND    PREGNANCY. 


gyiiJBCologists  have  fallen  into  this  error.  Irregular  hsemorrhagic  discharges 
may  persist  during  pregnancy  in  cases  of  fibrous  tumour.  It  may  •  be 
necessary,  in  order  to  clear  the  diagnosis,  to  use  a  fine  aspirating-needle 
in  the  interval  between  the  pains.  Fibroma  of  the  cervix  has  been  mistaken 
for  malignant  disease.  Here  attention  to  the  distinctive  features  of  carcinoma 
should  prevent  error.  Tumours  growing  from  the  pelvic  xvalls,  such  as 
fibromata,  ostcomata,  and  enchondromata,  may  l)e  mistaken  for  uterine 
fibromata.  Careful  exploration  to  determine  the  independence  of  the  uterus, 
under  an  aufesthetic,  will  prevent  this.  Fcecal  tumours  have  also  (Braxton 
Ilicks)  been  confounded  with  fibroma.  As  to  placenta  prcevia,  careful 
exploration  will  lead  to  a  recognition  of  the  characteristic  feel  of  the  placenta, 
though  of  course  a  fibroma  may  complicate  the  presentation,  and  this  must 
be  remembered  in  the  examination.     This  fact  is  important,  that  h£emorrhage 


ViG.  29i. — Interstitial  Fibromata  occueking  in  a  Uterus  in  which  Ti;iple 

Conception  occurred,  Delivery  being  effected  at  the  Ninth  Month. 
Three  large   myomata  occupy  the   entire   uterus ;    a   fourth   grows   from   the 
fundus,  to  which  three  smaller  cues  are  attached — ouc  of  these  is  becoming 
pediculated  and  subperitoneal.     There  was  no  rupture  (see  p.  430). 

is  more  likely  to  occur  during  the  latter  months  of  pregnancy  from  the 
placental  complication,  while  it  may  take  place  at  any  time  during  the  nine 
months,  and  may  last  all  through,  with  irregular  pains,  in  the  case  of  the 
uterine   tumour. 

The  existence  of  a  fibroma-myoma  may  only  be  accidentally  discovered 
when  an  examination  is  made  to  decide  the  question  of  pregnancy,  when  the 
hardness  of  the  mass  and  the  irregularity  of  the  surface  of  the  abdomen  will 
arouse  suspicion. 

Fibromitis  mistaken  for  Pregnancy. — Under  the  name  fibromitis  Meniere 
has  drawn  attention  to  an  interstitial  inflammation  of  fibroids,  caused  either 
hy  injiii'yi  exposure   to   cold,  or  occupation.     There   are   the   premonitory 


438 


DISEASES   OF   WOMEN, 


symptoms  of  inflammation — local  pain  and  tenderness,  general  malaise,  and 
constitutional  disturbance.  These  are  attended  by  rapid  enlargement  of 
the  tumour.  Sj'mptoms  of  pelvic  peritonitis  may  supervene.  If  suppuration 
should  occur,  the  usual  symptoms  attend  on  it.  Such  an  abscess  may  involve 
the  adjacent  viscera.  The  course  of  this  disease  is  tedious,  though  the 
prognosis  is  generally  favourable.  The  affection  must  not  be  confounded 
with  hgematocele,  pelvic  peritonitis,  or  renal  or  hepatic  colic. 


3   NAT. 


Fig.  295. 
A,  OS  uteri  externum.    B,  cut  edge  of  iDeritoneum  on  anterior  uterine  wall.     C, 
cut  edge  of  vaginal  reflection  pushed  down.     D,  vaginal  portion  of  tumour. 
E,  supra-vaginal  portion  of  tumour.    (W.  Duncan.) 

A  patient  supposed  to  be  in  the  third  month  of  pregnancy  had  passed  two 
menstrual  periods.  She  suffered  from  abdominal  tenderness,  pain,  and  sickness. 
All  the  symptoms  of  fibromitis  just  detailed  were  present.  Examination  dis- 
closed a  large  and  u'regularly  gi'owing  fibroma.  Time  proved  that  it  was 
uncomplicated  with  pregnancy. 

In  Elder's  case,*  on  the  "left  broad  ligament  there  was  a  series  of  small 
pedunculated  myomata,  in  all  about  the  size  of  a  foetal  head  at  term.  In  the 
uterine  wall  was  another  flattened  myomatous  mass,  and  other  nodules  existed 

*  Page  436. 


UTElilNE   yEOI'LA^'^MS—MYnUA    AAP    Pit  Ed  NANCY. 


4:5'J 


both  in  the  fundus  and  cervix.  Tlic  growth,  wliich  liad  caused  intestinal 
obstruction,  was  successfully  removed  by  supra-vaginal  extra-peritoneal 
hysterectomy,  an  important  feature  of  the  case  being  that  the  patient  had 
never  suspected  any  uterine  trouble  until  she  became  pregnant. 

The  drawing,  Fig.  2!)4,  is  one  of  an  interesting  case,  the  particulars  of 
which  are  recorded  by  McClintock  ('  Diseases  of  Women  '). 

It  represents  a  uterus  aifected  with  uiterstitial  fibromata,  which  was  taken 
shortly  after  death  from  a  woman  in  the  Kotunda  Hospital,  Dublin,  and  which 
is  in  its  museum.  There  was  a  triple  conception,  gestation  being  prolonged 
to  the  ninth  month.    The  mother  was  delivered  at  her  home  of  a  dead  female 


Fig.  296. — Pregnant  Uterus  with  Myuma — Hysterectomy.     Kecoveky. 
(MrsEUM  OF  Sanger's  Klinik,  Prague.) 
Patient,  aged  37,  a  multipara,  the  last  labour  having  taken  place  three  and  a 
half  years  previously.     Irregularity  of  the  catameuia,  followed  by  severe 
haemorrhage,  were  the  principal  symptoms.     The  uterus  was  removed  by 
supravaginal  amputation,  the  tumour  being  about  the  size  of  the  foetal  head, 
child.    She  was  brought  to  the  Piotunda,  where  a  second  child  was  born  alive, 
the  third  child  being  extracted.     She  died  in  three  hours,  of  collapse. 

William  Duncan  (Loudon)  records  an  interesting  case  *  (Fig.  295).  The 
patient,  aged  38,  had  had  several  pre^^ous  miscarriages — the  last,  eighteen 
months  prior  to  the  operation;  subsequently  to  which  the  gi'owth  had 
become  perceptible,,  gi-owing  into  a  smooth,  firm,  elastic  tumour,  reachmg 
to  the  nmbilicus.  Examination  under  anaesthesia  determined  the  presence 
of  pregnancy,  revealing  also  a  soft,  round,  red  tumour  filling  the  upper 
half  of  the  vagina,  and  apparently  springing  from  the  posterior  and  left  side 
of  the  cerA-ix,  and  at  these  parts  so  closely  adherent  to  the  vaginal  wall 

•  Lancet,  March  3,  1900. 


■±1U  DISEASES   OF    WOMEN. 

that  it  seemed  to  be  growing  into   it.     Pan-hysterectomy  was  performed 
successfully. 


"*4c-. 


Fig.  297. — Intekstitial  Pregnancy  in  Myomatous  Utebds — Hystekectomy  . 
(Museum  of  Sanger's  Klinik,  Prague.) 

This  specimen  was  taken  from  a  patient  aged  29,  who  had  had  two  previous 
labours,  the  last  occurring  five  years  previously.  For  six  weeks  after  the 
last  period  there  was  a  continuous  drain,  and  pain  in  the  hypogastria  and 
lumbar  region.  A  diagnosis  of  tubal  pregnancy  with  myoma  having  been 
made,  pan-hysterectomy  was  performed,  and  the  uterus  with  thu  adnexa 
and  a  hsematocele  sac  were  removed. 

Treatment  of  Myoma  complicated  with  Pregnancy. 
The  entire  question  of  the  practicability  of  operation  during  preg- 
nancy, either  for  ovarian  or  fibroid  tumour,  has  undei'gone  a  re- 
markable change  in  recent  years,  and  both  ovai'ian  and  parovarian 
cysts,  uterine  myomata  and  various  diseased  states  of  the  adnexa, 
have  been  operated  upon  during  this  complication.  Dealing  only 
here  with  fibro-myoma,  the  following  broad  j^rinciples  may  guide  us 
in  deciding  whether  or  not  to  interfere.  We  do  not  meddle  with  a 
pregnancy  proceeding  safely  in  the  presence  of  a  tumour  which  can 
be  disposed  of  as  the  pregnancy  advances,  such  as  a  pediculated 
fibromyoma,  a  small  subperitoneal  cervical  growth,  or  intra-liga- 
mentary  growths.  We  do  not  interfere  with  comparatively  small 
tumours,  especially  if  of  the  intra-mural  kind.  Only  when  serious 
complications  arise  during  the  pregnancy  which  threaten  the  life 
of  both  mother  and  child,  or  when  the  tumour  is  so  situated  that 


UTERINE  NEOPLASMS— M y^OMA   AND   PREGNANCY.  441 


its  removal  offers  the  best  chance  of  saving  both  lives,  while  non- 
interference risks  both,  should  operation  be  attempted.  Where 
such  a  probable  gain  cannot  be  hoped  for,  the  best  course  is  to  wait 
for  labour  and  perform  Cnesarian  section. 

Question  of  Operation. 

Kc'll}'  lays  down  the  rule  that  we  should ' always  rememlicr  that  two  lives  are 
iuvolved,aiul  if  possible  save  both,  rejecting  all  radical  measures  unless  the  symp- 
toms are  urgent.  Mere  prophylaxis— that  is  to  say,  operating  when  there  are 
no  urgent  symptoms  on  account  of  dangers  which  may  arise— has  no  tield  here.' 

Small  and  medium-sized  fundal  fibroids,  intra -ligaraentary  and  subperitoneal 
cervical  fibroids,  not  large  enough  or  so  placed  as  to  cause  dystocia  or  prevent 
labour,  and  pediculated  fibroid  tumours  which  can  be  pushed  up  into  the 
abdomen,  do  not  justify  interference  during  pregnancy,  while  interstitial 
tumours  should  not  be  touched  save  as  a  dernier  ressort,  as  abortion  almost 
necessarily  follows  their  removal,  though  extreme  pain  or  rapid  growth  may 
compel  interference.  A  pediculated  fibroid  projecting  into  the  vagina  may  be 
safely  removed.  In  short,  when  a  tumour  is  so  situated  that  its  removal  oilers 
the  best  chance  of  saving  mother  and  child,  while  non-interference  endangers 
the  lives  of  both,  operation  should  be  attempted.  Otherwise  we  must  wait  for 
labour  and  perform  Csesarean  section,  followed  by  hysterectomy.  The  need 
for  this  latter  step  will  depend,  Kelly  points  out,  upon  the  nature  of  the  tumour 
or  tumours,  whether  these  may  not  be  subsequently  removed  by  myomectomy 
without  ablation  of  the  uterus. 

With  regard  to  myoma  and  pregnancy,  Pozzi,  at  the  International  Medical 
Congress,  Paris,  1900,  stated  that  in  five  years  he  had  seen  eighty-three  cases 
of  myomata  in  twelve  thousand  and  fifty  confinements.  He  had  performed 
major  operations  in  four  cases,  operating  only  under  very  special  circumstances, 
and  regarding  neither  the  size  nor  the  situation  of  the  tumour  as  an  absolute 
indication ;  and  Hofmeir,  after  a  special  study  of  the  effects  of  myoma  on 
coifception,  pregnancy,  and  labour,  came  to  the  conclusion  that  a  myoma 
hinders  pregnancy  very  little,  and  does  not  frequently  affect  the  course  of  the 
labour.  Operative  interference  during  pregnancy  he  considers  to  be  seldom 
required,  and  can  only  become  necessary  at  its  termmation.  With  proper 
precautions  the  labour  is  nearly  always  accomplished  safely. 

Thumm,*  from  all  the  cases  published  since  1885  to  1902,  found  that  the 
mortality  of  abdominal  total  pan-hysterectomy  for  myoma  complicating  preg- 
nancy was  8-9  per  cent.,  and  supra-vaginal  amputation  11  per  cent.  Pinard, 
whose  opinion  is  specially  valuable,!  deprecates  any  surgical  interference  for 
such  tumours  during  pregnancy,  except  when  serious  accidents  force  the  hand 
of  the  operator.  At  the  Baudeloque  clinic,  out  of  25,000  parturient  women, 
85  had  uterine  myoma.  Only  twelve  were  operated  upon,  and  nearly  all  went 
their  fuU  term.  After  rupture  of  the  membranes,  if  difficulties  arise  he  advises 
Ceesarean  section  and  Porro's  operation  or  total  hysterectomy. 

Later  still,  in  the  discussion  at  the  American  Gynsecological  Congress  (June, 
1903),  Coe  classified  cases  under  three  heads :  (1)  Those  in  which  pregnancy 
would  doubtless  go  to  full  term  with  the  prospect  of  a  normal  delivery,  and 

*  ArcUv.f.  Gyti.,  bd.  Ixiv.,  Heft  3.  t  Ln  Gyn.,  Oct.  15,  1901. 


442  DISEASES   OF   WOMEN. 


in  which  the  treatment  was  entirely  expectant.  (2)  Those  requiring  constant 
observation  mth  the  possible  anticipation  of  the  date  of  noiToal  delivery. 
(3)  Those  in  which  there  was  considerable  risk  to  the  mother  or  child,  or 
both,  before  and  during  labour,  and  requiring  surgical  treatment  either  conser- 
vative or  radical. 

He  advocated  the  adoption  of  these  lines  of  treatment :  For  iixed 
fibroids  low  down  in  the  pelvis,  the  emptying  of  the  uterus  and  subsequent 
myomectomy.  Unless  urgent  symptoms,  arising  from  signs  of  cardiac, 
renal,  pulmonous  or  interstitial  complications,  were  present,  sessile  tumours 
should  not  be  removed.  Only  when  they  threatened  life  should  radical 
measures  be  taken.  He  advises  in  such  cases  the  induction  of  labour 
at  the  thirty-fifth  or  thirty- sixth  week,  but  after  the  eighth  month  action 
should  be  deferred  as  long  as  possible  before  an  elective  section  be  made. 
The  general  trend  of  opinion  was  on  the  lines  above  indicated,  and  several 
speakers,  as  Eeynolds,  Pryor,  and  Englemann,  emphasize  the  need  for  recog- 
nition of  the  softening  process  which  occurs  in  the  tumour  pari  passu  with 
the  progress  of  the  pregnancy.  On  the  whole,  the  operation  of  myomectomy 
was  preferred  to  hysterectomy. 

The  experience  of  Donald  *  is  practically  similar :  '  In  most  cases  it  is 
better  to  wait  till  term.  If  interference  be  imperative,  the  choice  lies  between 
hysterectomy  and  myomectomy.  Csesarean  section,  a  Porro,  or  hysterectomy, 
are  the  alternatives  at  term. 

Carstens,  on  the  other  hand,t  argues  that  all  tumours  likely  to  interfere  with 
labour  should  be  operated  upon,  as  there  is  less  danger  in  their  removal  during 
pregnancy  than  non-interference,  and  letting  the  woman  go  to  full  term,  all 
tumours  taking  on  a  rapid  growth  during  pregnancy.J 

As  bearing  on  the  practical  point  of  dilatation  of  the  cervix 
uteri  when  a  myoma  complicates  pregnancy,  and  where  such  further 
complications  as  albuminuria,  eclampsia,  or  any  form  of  contracted 
pelvis  is  present,  it  is  a  matter  of  vital  moment  to  be  able  to  dilate 
the  cervix  to  the  point  of  safe  instrumental  delivery.  To  do  tnis 
rapidly,  and  with  safety  to  the  integrity  of  the  uterus  and  the 
presenting  part  of  the  foetus,  must  be  our  aim  when  from  any  of 
these  complications  we  have  to  empty  the  uterus.  For  this  object 
the  instrument  devised  by  Bossi  is  most  valuable. 

Its  construction  can  be  understood  from  the  accompanying  draw- 
ing. It  will  be  seen  that  it  consists  of  four  branches,  or  blades, 
which,  when  approximated,  form  a  single  grooved  end  about  2|  inches 
in  length.  This  can  easily  be  inserted  into  any  patulous  cervix.  The 
grooves  prevent  it  from  slipping  in  the  cervical  canal.  By  the 
construction  of  the  instrument,  the  screw  moves  the  branches 
synchronously.    Without  entering  into  the  details  of  its  mechanism, 

*  Lancet,  June,  1901.  t  Amer.  Jour.  Obst.,  March,  1903. 

X  Two  interesting  cases  of  abdominal  hysterectomy  for  myoma  complicating 
pregnancy  are  recorded  in  the  April  number  of  the  Journal  of  Obstetrics  and 
Oynascology  of  the  British  Empire,  by  Florence  Boyd. 


UTERTNE  NEOPLASM:^— MYOMA    AND   PREGNANCY. 


443 


it  is  sufficient  to  say  that  when  the  wheel-handle  is  rotated  the 
blades  can  be  made  to  diverge  to  the  extent  of  eight  or  more  centi- 
metres, while  the  dilatation  is  measured  by  a 
pointer  and  scale,  showing  the  extent  to  which 
the  branches  are  separated.*  Bossi's  original 
instrument  has  been  moditied  by  Preiss,  and  later 
still  by  Frommer.  Fig.  299  shows  Preiss'  in- 
strument, side  by  side  with  Frommer's.  When 
dilatation  has  proceeded  up  to  a  certain  point, 
the  dilator  is  withdrawn,  and  the  shields  are 
placed  on  the  branches.  These  are  agaia  ap- 
proximated, and  reintroduced  into  the  uterus, 
when  the  dilatation  is  proceeded  with.  There 
should  be  no  hurry  in  the  dilatation,  the  instru- 
ment being  worked  slowly  and  with  periodical 
rests.  Complete  aseptic  precautions  are  taken 
before  using  the  instrument. 

Myoma  complicating'  Pregnancy,  with  Albu- 
minuria.— As  it  was  the  tirst  occasion  in  this 
country  in  which  the  dilator  of  Bossi  was  used,t 
and  as  the  case  in  which  I  then  employed  it 
exemplifies  the  value  of  the  instrument,  I  give 
the  details  here. 

A  lady,  early  in  the  seventh  month  of  pregnancy,  was  attacked 
with  somewhat  severe  htemorrhage.  She  had  been  suffering  from 
albuminuria  for  some  time,  and  this  had  increased  until  the  urine 
was  almost  solid  on  boiling.  There  were  no  uremic  symptoms,  nor 
any  cei'ebral  or  visual  disturbances.  Haemorrhage  recurring,  with 
attacks  of  syncope  and  sickness,  while  the  foetal  pulsations  and 
projections  were  absent,  rapid  dilatation  and  delivery  of  the  child 
was  determined  upon.  Under  ancesthesia,  the  patient  was  carefully 
prepared,  and  the  vagina  sterilized.  The  fundus  of  the  uterus  was 
found  to  be  myomatous.  In  twenty  minutes,  without  any  lesion  of 
the  cervix  or  rupture  of  the  membranes,  dilatation  was  effected  to 
the  extent  of  six  and  a  half  centimetres.  The  myoma  prevented 
further  dilatation.  The  presentation  was  that  of  an  arm,  with  the 
head  lying  in  the  left  iliac  fossa.  As  it  was  found  impossible  to 
move  the  presentation,  the  membranes  were  ruptured.  In  the 
attempt  to  bring  the  head  into  position  the  arm  came  down,  with 

*  Professor  L.  :M.  Bossi,  Svlla   Bilatazione  Meccanica  Immediata  del  CoUo 
deir  Utero  nel  Campo  Ostetrico  Annali  di  Odetricia  e  Ginecologia.  1000. 
t  Brit.  Gyn.  Jour,,  Feb..  1902 ;  Lancet.  INIarch  1,  1902. 


Fig.  298.— Bossi's 
Dilator. 


444 


DISEASES   OF   WOMEN. 


a  loop  of  the  funis.  In  consequence  of  the  impossibility  of  intro- 
ducing the  hand  into  the  uterus,  the  greatest  difficulty  was  expe- 
rienced in  effecting  version.  By  pushing  back  the  arm  and  raising 
the  head,  the  foot  was  ultimately  secured  and  version  effected. 
Great  difficulty  was  also  experienced  with  the  after-coming  head, 
which  was  finally  delivered  by  using  the  blade  of  a  forceps  as 
a  vectis.  The  placenta  was  shortly  afterwards  delivered.  The 
foetus  was  discoloured,  and  decomposition  had  set  in,  with  attendant 
desquamation.     There  had  evidently  been  placentitis,  with  exuda- 


\d 


Fig.  299.— Feommee's  (1)  and  Peeiss'  (2)  Modifications  of  Bossi's  Dilators. 
The  former  has  eigU  detachable  blades,  thus  enabling  the  operator  to  regulate 
the  number  in  use  at  any  time  during  the  dilatation.     A,  shields  for  the 
ends  of  the  blades ;  B,  the  blades  close'd  with  the  shields  on ;  C,  the  blades 
closed  without  the  shields.     Personally  I  prefer  the   original   Bos.si's  or 
Preiss'  instrument. 
tions  in  parts  and  degeneration,  causing  in  one  portion  a  rather 
large  separation,  with  resulting  extravasation.     Fearing  that  there 
might  be  portions  of  placental   tissue  remaining,   the  uterus  was 
several  times  explored   with  an  ovum  forceps,  and  some  placental 
debris  was  removed.    The  uterus  was  then  douched  out  with  formalin 
solution.     Two  slight  lacerations  caused  by  the  delivery  of  the  head 
were  secured  with  cumol  gut,  and  the  vagina  was  loosely  tamponed 
with  iodoform  gauze.     The  whole  time' occupied  from  the  commence- 
ment to  the  close  of  the  operation  was  exactly  one  hour. 


CHAPTER  XXIV. 

UTERINE   NEOPLASMS— MYOMA  (continued). 
SURGICAL   TREATMENT. 

Methods  of  and  Indications  for  Operation. 

It  would  serve  no  useful  purpose  in  this  work  to  enter  into  a 
historical  resume  of  the  gradual  development  of  the  present-day 
methods  of  the  operation  of  hysterectomy,  from  the  time  when 
Charles  Clay,  in  England  (1844),  performed  it  first,  to  the  latest 
technique  of  the  operation.  Within  the  last  ten  years  some 
operative  procedures  have  become  practically  obsolete,  not  only 
in  this  country  and  America,  but  in  all  the  principal  clinics  of 
Europe.  I  do  not,  therefore,  occupy  space  in  describing  these 
methods.  The  names  of  Hegar,  Lawson  Tait,  Schroeder,  Olshausen, 
Sanger,  Wolfler,  and  Hacker  are  those  of  the  pioneers  in  these 
various  extra-peritoneal  and  mixed  techniques.  Though  interesting 
from  the  historical  point  of  view,  they  have  become  obsolete  as 
modern  surgical  methods. 

Classification  of  Methods. 

I  must  limit  the  discussion  of  the  surgery  of  uterine  myoma  to  the 
procedures  which  are  now  more  generally  adopted  by  gynagcologists 
and  those  which  I  myself  follow.  We  may  divide  these  procedures 
thus : — (1)  Operative  measures  for  restraining  hasmorrhage  and 
arresting  the  growth  of  the  tumour.  (2)  Operations  for  conserving 
the  uterus  while  removing  the  myoma  or  myomata.  (3)  Operations 
for  removal  of  the  tumour  without  opening  mto  the  vagina.  (4) 
Operations  for  removal  of  the  entire  uterus  and  the  adnexa : 
(a)  abdominal  pan-hysterectomy  ;  (h)  vaginal  pan-hysterectomy. 
(5)  Operations  for  removal  of  tumours  of  the  broad  ligaments  and 
adnexa,  in  which  the  uterus  may  or  may  not  have  to  be  removed. 

The  form  of  operative  measure  pursued  for  the  treatment  of  a 
uterine  myoma,  whether  it  be  a  single  tumour  or  of  the  multiple 


446  DISEASES   OF    WOMEN. 

nature,  will,  as  we  have  said,  depend  upon  the  characteristics  of  the 
growth  or  growths  which  have  to  be  removed.  It  may  be  well  to 
summarize  these  various  procedures,  beginning  with  those  which  do 
not  interfere  with  the  uterus  itself.  It  is  not  possible  to  define,  nor 
indeed,  from  what  has  been  already  said,  can  we  accurately  differen- 
tiate, the  exact  indications  for  any  special  surgical  method  of  dealing 
with  myoma.  Some  broad  limitations  there  are  to  the  choice  of 
each  particular  method,  and  these  may,  for  practical  purposes,  be 
appended  to  each. 

Operative  Measures  for  restraining  Haemorrhage  and  arresting 
the  Growth  of  the  Tumour. 

Ligation  of  the  uterine  and  ovarian  arteries. 
Salpingo-oophorectomy. 

In  cases  in  which  haemorrhage  is  the  principal  source  of  danger  in 
the  earlier  days  of  the  growth  of  the  myoma,  and  when  a  patient  will 
not  consent  to  any  more  serious  operative  procedure,  ligation  of  the 
uterine  and  ovarian  vessels,  as  first  advocated  by  Robinson  and 
Martin  of  Chicago,  may  be  practised  with  a  view  to  checking  haemor- 
rhage and  increasing  atrophy  of  the  tumour, 

Salpingo-oophorectomy  is  still  performed  in  specially  selected  cases, 
though  not  to  the  same  extent  as  it  was  some  time  back.  Speaking 
generally,  it  is  only  indicated  in  the  case  of — 

(a)  Comparatively  small  tumours ; 

(&)  Rapidly  growing  tumours  in  women  under  thirty ; 

(c)  Small  interstitial  fibroids  ; 

(d)  Intraligamentary  fibroids  in  their  early  stages  ; 

(e)  When  under  such  conditions  there  is  uncontrollable  and  per- 
sistent haemorrhage  of  a  dangerous  nature ; 

(f)  When  the  patient  will  not  consent  to  hysterectomy,  and  where 
the  haemorrhage  is  severe. 

It  should  not  be  performed  when  the  tumour  is  large,  fibro-cystic, 
or  pediculated,  and  it  is  contra -indicated  in  serious  adnexal  com- 
plications with  inaccessible  ovaries  and  tubes. 

Operations  for  conserving  the  Uterus  while  removing  the 
Myoma  or  Myomata. 

Myomectomy  and  myotomy : 
{a)  Abdominal ; 
'   (&)  Vaginal ; 
Myomectomy  with  morcellement. 


PLATE    XXX J X 


GlAXT    riBKO:MV'.OI.' 


The  patient  from  whom  the  tumour  was  removed  was  a  multipara,  aged  50. 
Her  last  pregnancy  occurred  eleven  years  previously. .  She  had  never 
suffered  any  particular  pain,  and  could  not  date  the  commencement  of  tlie 
growth,  which  she  had  only  noticed  some  two  years  before  I  saw  her  in- 
1898,  and  only  within  the  last  few  montlis  had  there  beau  a  rapid  increase 
in  size.  The  periods  had  been  irregular  in  occurrence  and  quantity,  and 
there  was  a  considerable  loss  a  few  days  before  operation.  On  examination 
a  large  movable  abdominal  tumour  was  found,  semi-solid  to  the  touch,  and 
associated  with  the  uterus,  the  cavity  of  which  was  over  live  inches  in 
length.  The  abdomen  was  enlarged  much  beyoad  the  size  of  the  full  term- 
of  pregnancy.  The  patient  was  fully  aware  of  the  risk  connected  with  the 
operation.  The  enormous  tumour  was  found  to  be  free  from  adhesions, 
and  was  delivered  through  an  incision  reaching  from  below  the  ensiform 
cartilage  to  the  pubes.  A  broad  pedicle  attached  it  to  the  left  broad 
ligament,  and  there  was  a  separate  attachment  to  the  uterus.  The  capsule 
having  been  completely  detached  by  a  circular  incision  and  stripped  down, 
the  attachment  to  the  uterus  was  secured  and  supra-vaginal  hysterectomy 
completed.  The  large  broad  ligament  pedicle  was  then  ligatured  in 
segments  and  the  tumour  was  detached.  After  removal  it  was  found  that 
the  bladder  had  been  opened.  The  wound  was  closed  by  catgut  sutures- 
and  a  catheter  was  retained.  The  operation  lasted  altogether  two  hours, 
and  during  the  last  half-hour  sub-cutaneous  (sub-mammary)  injections  of 
artificial  serum  were  maintained.  The  anesthetic  given  was  chloroform. 
There  was  dangerous  collaiDse  on  the  delivery  of  the  tumour,  and  again 
towards  the  close  of  the  operation.  As  there  was  some  bleeding  from  the 
bladder,  it  was  washed  out  at  intervals  with  a  solution  contaiidiig  30 
minims  of  liquid  extract  of  suprarenal  capsule.  The  tumour  proved  to  be 
a  solid  fibromyoma,  and  it  weighed  28J  pounds.  Its  size  atid  shape  can 
be  estimated  from  the  accompanying  illustratiuus  taken  from  photographs 
(Plate  XXXIX.).  The  table  on  which  the  tumour  rests  measures  16  X  16 
inches.  (The  uterus  and  aduexa  are  not  shown.)  The  patient  is  in 
excellent  health. 

[To  face  p.  446. 


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UTEniXE  XEOPLA.'<MS— MYOMA— SURG rCAL    TREATMEST.    447 

Myotomy  is  applicable  to  certain  cases  of  intra-uterine  or  sub- 
mucous myoma,  the  attack  on  the  tumour  being  made  from  the 
cervix  to  the  vaginal  side.  Morcellation  may  be  combined  with  the 
myotomy,  where  the  tumour  proves  dillicult  of  isolation,  and  in  the 
case  of  larger  and  more  friable  growths.  Ligation  of  the  uterine 
vessels,  after  separation  of  the  Ijladder  and  detachment  of  the 
peritoneum,  may  be  necessary  steps  in  the  operation.  Pediculated 
myomata  are  treated  by  myomectomy.  WUliam  Alexander  has 
succinctly  summarized  the  indications  for  enucleation. 

'  (a)  Tumours  producing  any  serious  signs  or  symptoms  of  disease, 
crippling  the  patient,  and  interfering  with  marriage,  pregnancy,  or 
happiness. 

'  (b)  When  such  tumours  are  solitary,  or  not  exceeding  three  or 
four  in  number,  and  all  are  capable  of  being  removed  through  one 
incision  into  the  fundis  uteri. 

'  (<')  When  the  uterus  and  appendages  are  sufficiently  healthy  to 
perform  their  functions  enucleation  should,  when  possible,  be 
performed. 

'  {d)  The  size  of  the  tumour  or  tumours  does  not  signify,  pro'V'ided 
that  a  healthy  uterus  can  be  left  behind.' 

The  advantages  of  enucleation  over  hysterectomy  in  suitable  cases 
are — 

'1.  It  is  not  a  deprivative  operation,  and  hence  it  can  be  performed 
earlier  when  patients  are  only  .crippled  or  worried  by  the  disease,  and 
before  dangerous  symptoms  set  in. 

'  2.  The  shock  of  operation  and  risks  to  the  patient  in  these  early 
enucleations  are  much  less  than  in  hysterectomy  later  on.  The 
mortality  is  not  more  than  two  per  cent. 

'  3.  ^larriage,  pregnancy,  and  parturition  are  possible,  and  relief 
will  be  accepted  by  patients  in  this  way  who  would  continue  to 
suffer  rather  than  have  hysterectomy  performed,  or  their  ovaries 
removed.' 

Operations   for   removal  of  the  Tumour   without  opening  into 

the  Vagina. 

Supra-vaginal  Hysterectomy — Hystero-myomectomy  (Kelly). — 
This  operation,  which  is  generally  associated  with  Howard  Kelly's 
name,  involves  the  abandonment  of  the  cervix  uteri,  and  may  or  may 
not  involve  the  removal  of  the  adnexa  of  one  or  both  sides,  according 
as  they   are   diseased   or  otherwise,  and  as  the  operator   deems  it 


448  DISEASES   OF    WOMEN. 

advisable  for  physiological  or  clinical  reasons.  The  classical  condition 
which  indicates  it  is  a  myoma  of  any  size  uncomplicated  by  extensive 
adnexal  adhesions,  suppurative  states  of  the  adnexa,  diseased  con- 
ditions of  the  cervix,  degenerative  changes  in  the  tumour  involving 
the  cervix,  any  suspicion  of  malignant  change,  and  intra-ligamentary 
tumours.  It  has  the  advantage  of  a  simpler  and  more  rapidly  com- 
pleted technique,  and  the  vault  of  the  vagina  is  preserved  intact. 
It  has  the  disadvantage  of  leaving  the  cervical  stump,  which  is  liable 
to  various  degenerative  changes  in  the  future,  and  possibly  those  of 
a  malignant  nature.  There  may  also  be  risk  of  sepsis  through  the 
infected  cervix  and  the  want  of  drainage.  Though  on  the  whole 
there  cannot  be  said  to  be  as  great  risk  of  sepsis  as  in  the  pan- 
hysterectomy operation,  this  and  the  next  operation  may  have  to  be 
completed  by  bisection  of  the  uterus. 

Operations  for  the  Removal  of  the  Entire  Uterus  and  Adnexa. 

Pan  -  hysterectomy  (Coelio  -  salpingo  -  odphoro  -  hysterectomy) 
Abdominal  Pan-hysterectomy. — This  is  the  most  complete  and 
perfect  of  all  operations  for  the  removal  of  myomata.  It  is  more 
specially  called  for  where  there  are  tumours  which  involve  the 
broad  ligaments,  and  ■  in  which  the  cervix  participates  in  the 
myomatous  change.  It  is  also  the  operation  for  myomatous  tumours 
complicated  by  suppurative  states  of  the  ovaries  or  tubes  where 
there  has  been  serious  perimetritic  inflammation  resulting  in 
adhesions  of  the  pelvic  viscera ;  where  there  are  cystic,  necrotic, 
suppurative,  adenomatous,  or  malignant  degenerations  of  the  myoma, 
especially  if  these  involve  the  cervix.     Hegar  *  thus  puts  it :  — 

'  Abdominal  total  extirpation  is  indicated  in  complicated  cases,  such  as  those 
iu  which  the  tumour  hes  partly  in  the  smaller  pelvis,  develops  and  unfolds  the 
peritoneal  layers  of  the  lower  portions  of  the  broad  ligaments,  extends  as  far 
as  the  lateral,  or  even  the  posterior  wall  of  the  pelvis,  approaches  the  hypo- 
gastric vessels  or  the  ureters,  elevates  the  back  part  of  the  broad  ligament,  or 
separates  the  mesentery,  so  that  the  sigmoid  flexure  on  the  left  and  a  loop  of 
small  intestine  on  the  right  lie  across  the  tumour.  The  branches  of  the 
uterine  arteries  are  often  thrust  asunder  and  some  pushed  forwards  and  others 
backwards.  Occasionally,  to  obtain  a  better  view,  one  is  obliged  to  take  away 
individual  nodules  or  sections  of  the  growth.  If  changes  have  taken  place  in 
the  tumour,  such  as  effusions  of  blood,  necrosis,  or  cystic  degeneration,  there 
are  often  also  very  extensive  adhesions  rich  in  blood  supj^ly,  especially  to  the 
omentum.  Finally,  pathological  changes  in  the  adnexa  are  by  no  means 
rare.     Under  such  circumstances  the  operation  cannot  be  done  quickly,  but  is 

*  Miiwh.  m.  WcMk,  1902,  No.  47. 


UTEltlSE   NEOrLAtiMS—M yOMA—SUEG ICAL    TIIEATMEM.     U\i 

nevertheless  especially  indicated  and  has  many  advantages  over  any  other 
method.'     Bisection  uf  the  uterus  is  frequently  a  step  in  this  technique. 

Vaginal  pan-hysterectomy  performed  by  the  vaginal  route  is, 
with  a  number  of  gynjecological  surgeons,  regarded  as  the  classical 
method  of  removing  a  myomatous  uterus.  The  grounds  on  which 
they  arrive  at  this  decision  are,  that  the  operation  itself  is  less  for- 
midable, there  is  less  exposure  of  the  bowel  and  peritoneal  cavity, 
less  danger  of  sepsis,  less  shock,  and,  when  necessary,  drainage  is 
more  easily  secured.  The  operation  is  specially  indicated  in  the 
case  of  a  comparatively  small  myoma  under  the  size  of  the  fcetal 
skull  at  full  term,  in  which  we  have  no  broad  ligament  complica- 
tions, nor  serious  adnexal  complications  or  adhesions.  It  may  be 
performed  by  means  of  ligature,  ligature  and  angiotripsy,  or  with 
various  kinds  of  clamp.  Pan-hysterectomy  is  also  performed  by 
means  of  electro-ha^mostasis  (Skene  and  Jacobs). 

Operations  for  Removal  of  Myomatous  Tumours  of  the  Broad 
Ligaments  and  Adnexa  in  which  the  Uterus  may  or  may 
not  have  to  be  Removed. 

Decortication.^ — This  operation  may  be  performed  alone,  or  supple- 
mented by  supra-vaginal  hysterectomy.  It  is  especially  applicable 
to  tumours  springing  from  the  broad  ligaments  and  adnexa.  Peeling 
off  the  peritoneal  covering,  resection  of  the  tumour,  closure  of  its 
bed  by  sutures ;  drainage  either  by  the  vagina  or  the  abdominal 
wound,  according  to  circumstances,  such  as  the  size  of  the  tumour 
and  its  attachment  or  proximity  to  the  uterus. 

Mortality  and  Risk  of  Operation. 

It  would  serve  but  little  useful  purpose  to  enter  into  the  various 
disputations  and  statistical  records  of  different  operators,  whether 
Continental,  American,  or  British,  on  the  comparative  advantages 
of  this  or  that  method  of  removing  uterine  fibromata.  The  results 
arrived  at  by  the  most  eminent  surgeons,  by  what  they  assert  to  be 
the  same  method  of  operation,  prevent  any  definite  conclusion  which 
can  be  drawn  from  statistical  records.  This  is  only  what  we  may 
expect  when  we  recollect  the  intrinsic  difficulties  and  differences 
arising  in  all  of  these  operative  procedures.  Obviously,  the  exact 
suitability  of  this  or  that  method  to  any  individual  case  must  vary 
according  to  the  nature  of  the  tumour  and  the  local  complications. 
A  general  survey  of  experiences  of  a  large  number  of  operators,  and 

2   G 


450  DISEASES   OF    WOMEN. 

the  results  of  some  thousands  of  cases,  shows  that  the  special  appli- 
cability of  any  mode  of  manipulation  must  be  determined  by,  and 
made  subservient  to,  the  particular  necessities  of  the  type  of  tumour 
which  is  at  the  moment  being  dealt  with. 

The  main  aims  of  all  opei'ators,  and  in  every  abdominal  operation, 
can  be  summarized  as  follows  : — 

Essentials  to  aim  at. 

(«)  Reduction  of  the  time  of  operation  to  the  lowest  possible 
period  compatible  with  its  complete  performance. 

(h)  Protection  of  the  bowel  from  injury,  and  possible  subsequent 
adhesions  and  consequent  obstruction. 

(c)  Complete  hsemostasis. 

(d)  The  prevention  of  shock. 

(e)  Avoidance  of  injury  to  the  bladder  and  ureters. 

(/)  Thorough  asepsis  before,  during,  and  after  operation. 

Whichever  operation,  to  the  surgeon's  mind,  covers  these  .safe- 
guards most  completely  from  the  risks  inseparable  from  the  per- 
formance of  most  grave  cceliotomies  or  vaginal  hysterectomies,  is  the 
one  that  he  should  select,  and  there  is  the  further  important 
consideration  that  he  alone  knows  the  kind  of  procedure  in  which 
he  has  the  greatest  confidence  in  his  own  operative  skill  to  complete, 
of  "which  he  has  the  largest  experience,  and  which  he  personally 
believes  will  give  to  that  particular  patient  the  largest  proportion  of 
chances  of  satisfactoiy  recovery. 

In  earlier  editions  of  this  treatise  the  question  of  the  statistical 
evidence  as  to  the  relative  mortality  of  extra-  and  intra-peritoneal 
operations  was  fully  discussed.  The  work  which  has  been  done  has 
of  late  years  conclusively  shown  that  the  various  intro-peritoneal 
operations  performed  by  the  vaginal,  celio-vaginal,  and  supra-vaginal 
methods  are  the  safest,  that  they  are  capable  of  such  modifications 
of  technique  as  may  be  demanded  by  the  peculiar  conditions  of  the 
tumour,  and  also  afford  the  surgeon  the  greatest  security  for  the 
successful  accomplishment  of  those  important,  if  not  vital,  objects 
just  enumerated.  We  are  justified  in  arriving  at  such  a  conclusion 
from  a  scrutiny  of  the  results  achieved  by  a  host  of  distinguished 
surgeons  who  have  practised  both  procedures. 

Within  the  last  few  years  the  mortality  has  decreased  relatively 
with  the  improved  aseptic  and  antiseptic  precautions,  more  careful 
diagnosis  and  selection  of  cases  for  a  given  procedure,  more  perfect 
peritoneal   adaptation   and    adjustment,  more    rapid  and  complete 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.    451 

hnemostasis,  less  frequent  use  of  the  drainage  tube,  and  a  better 
differentiation  of  the  cases  in  which  drainage  is  indicated. 

The  mortality  by  any  method  of  operation  will  depend  upon  the 
conditions  and  complications  met  with  in  the  cases  operated  upon. 
The  diflerence  in  the  risks  between  various  cases  is  great,  and 
cannot  often  be  determined  before  operation.  Therefore,  in  stating 
such  risk  to  the  patient,  as  should  always  be  done,  a  margin  must 
be  allowed  for  unforeseen  accidents  and  obstacles.  Allowance,  too, 
must  be  made  for  extra  danger  in  the  case  of  very  large  tumours 
with  ascertained  adhesions  situated  deeply  in  the  pelvic  cavity,  and 
involving  the  adjacent  viscera. 

Idiosyncrasies  and  temperament  must  also  be  well  weighed,  and 
the  presence  of  any  constitutional  vice  or  lesion  of  the  lung  or  kidney 
in(j[uired  into. 

In  the  face  of  such  conditions  as  cardiac  disease,  chronic  asthma, 
general  atheroma,  or  renal  disease,  the  surgeon  will  pause  before 
advising  hysterectomy. 

The  mortality  returns  of  the  most  expert  operators  vary  widely, 
and  we  may  take  it  that  the  risk  involved  in  the  most  perfect 
removal  of  non-pediculated  fibromata  ranges  from  4  to  10  per  cent. 
In  certain  pediculated  cases,  where  the  difficulty  is  not  greater  than 
that  involved  in  an  ordinary  ovariotomy,  the  risk  is  not  more  than 
in  the  latter  operation,  say  2  per  cent.  The  truth  is,  that  each 
individual  case  of  myoma  has  associated  with  its  removal  its  own 
particular  danger,  and  it  is  wrong  for  any  operator,  on  the  ground 
of  any  favourable  statistical  table  or  successful  run  of  operations, 
to  minimize  this  danger  to  his  patient.  The  probable  risk  in  the 
case  of  the  particular  tumour  under  discussion  is  what  he  has  to 
forecast ;  not  what  is  the  percentage  risk  of  the  operation  in  all 
cases. 

Symptoms  Demanding  Operation. 

It  must  ever  be  of  importance  to  the  practitioner  to  recognize 
those  symptoms  on  the  presence  or  recurrence  of  which  he  will 
recommend  or  acquiesce  in  so  serious  a  step  as  hysterectomy.  There 
are  clear  cases  in  which  there  is  no  choice  save  operation,  when  life 
is  seriously  threatened,  either  by  the  large  size  of  the  tumour,  pelvic 
complications,  pressure  on  the  ureters  and  rectum,  scA'ere  haemor- 
rhage, great  suffering,  suppuration,  or  interstitial  changes  in  the 
tumour.  The  decision  or  the  justification  for  operation  for  a  fibroid 
tumour  must   depend   on  the   answer  to  these  questions.     Is   the 


452  DISEASES   OF    WOMEN. 


tumour  at  the  moment  a  source  of  immediate  danger  to  the  life  of 
the  woman  :  does  it,  by  its  rapidity  of  growth,  its  size  or  position, 
or  the  symptoms  that  it  causes,  render  it  more  than  probable  that 
the  pursual  of  an  expectant  attitude  will  expose  her  to  greater  risks 
than  those  that  must  be  incurred  by  the  operation  on  the  particular 
tumour  in  the  individual  case  before  us  ? 

We  are  not  justified  in  advising  operation  if  we  do  not  conscien- 
tiously feel  that  the  danger  of  interference  is  at  least  not  greater 
than  that  which  would  follow  non-interference.  The  considerations 
to  which  weight  has  to  be  attached  in  arriving  at  a  conclusion  are 
the  presence,  constant  or  periodical,  of  pain  that  no  treatment  can 
alleviate ;  the  obvious  evidences  in  the  woman's  appearance,  and 
from  her  history,  that  the  tumour  is  gradually  but  certainly  under- 
mining her  health ;  that  her  social  position  is  such  as  to  prevent  her 
taking  advantage  of  palliative  means  of  treatment,  and  that  she  is 
unable  to  support  herself  or  her  family  by  her  personal  exertion.  A 
tumour  that  may  be  well  borne  and  temporized  with  in  the  instance 
of  one  woman,  will  demand  in  the  other  operative  interference  for 
the  earning  of  her  daily  bread  and  domestic  considerations. 

Early  Operation.^The  determination  of  early  operation  after  the 
discovery  of  a  fibroid  tumour  of  the  uterus  will  depend  upon  its 
position,  size,  comparative  facility  of  removal  by  such  means,  for 
example,  as  myomectomy,  or  vaginal  hysterectomy,  or  its  treatment 
by  ligation  of  the  uterine  arteries,  or  salpingo-oophorectomy. 

The  tumour  may  complicate  retroversion  of  the  womb,  may  be 
connected  with  disordered  mental  states,  and  be  found  associated 
with  morbid  conditions  or  tumours  of  the  adnexa.  Such  complica- 
tions may  demand  its  early  removal.  What  must  be  insisted  upon 
is,  that  the  mere  presence  of  a  fibromyoma  does  not  justify  an  opera- 
tion. It  may  happen  that  a  comparatively  large  tumour  can  with 
safety  be  temporized  with,  while  a  relatively  smaller  one  must  be 
removed.  The  fact  cannot  be  overlooked  that  most  women  who  sufi'er 
from  tumours  of  the  womb  or  the  adnexa  are  more  or  less  invalids. 
Discomfort,  inability  to  walk,  pain,  haemorrhage,  constipation, 
bladder  troubles,  mental  distress  and  apprehension,  deprivation  of 
social  enjoyments,  incapacity  for  fulfilling  ordinary  duties  or  those 
demanded  by  occupation,  are  common  consequences. 

The  majority  of  women  who  sufi'er  thus  will  themselves  demand 
that  relief  afibrded  by  operation,  even  when  distinctly  told  the 
maximum  risk  which  they  have  to"  run  in  order  to  be  cured. 

The  old  idea  of  waiting  for  the  menopause  in  order  to  give  the 


PLATE    XLT. 


Large  Dense  Fibroma,  of  Stony  Hardness,  filling  the  Pelvic  Cavity,  ani>- 

FIXED    BY  ADH£SI0^S  TO    THE    ReCTUBI    AND    FlOOR    OF    THE    PeLVIS.     (AuTHOR.) 

(Case  referred  to  p.  453.) 

ITofacep.  453-;. 


UTERTXE  NEOPLASM s—M YOMA— SURGICAL    TREATMENT.    453 

tumour  a  chance  of  disappearance,  has  long  since  been  exploded. 
All  tlie  risks  of  the  :ipproa(tliing  menopause  are  increased  by  its 
presence,  and  its  dangers  are  accentuated.  Of  this  fact  there  are 
some  striking  examples  in  these  pages.  This  has  to  be  said  on  behalf 
of  the  advocates  of  hysterectomy  in  the  early  stages  of  the  growth 
of  fibroids,  that  the  dangers  attendant  upon  operation  would  be  con- 
siderably diminished  by  their  removal  when  of  small  size. 

Here  the  operation  of  selection  undoubtedly  is  myomectomy,  if 
the  tumour  or  tumours  be  suitable.  The  present  trend  of  opinion  is 
in  the  direction  of  early  removal  by  the  vagina  of  growing  interstitial 
fibromata  to  which  other  procedures  are  not  applicable  in  the  most 
favourable  circumstances. 

In  any  case  the  risk  involved,  whatever  operation  be  performed, 
should  be  fairly  placed  before  the  patient.  If  it  has  to  be  done 
under  circumstances  that  render  it  exceptionally  dangerous,  the  per- 
centage of  deaths  from  interference  in  that  particular  type  of  case 
should  be  explained  to  her.  This  is  my  practice,  and  I  may  illus- 
trate it  by  the  following  example  : — 

A  lady  consulted  me  who  had  sufiFered  from  a  fibromyoma  for  some  years. 
She  was  then  anaemic,  rather  emaciated,  and  of  a  highly  nervous  and  hysterical 
temperament.  She  suffered  constant  pain,  and  was  unable  to  walk  any 
distance.  Active  haemorrhage  had  ceased.  The  summit  of  the  tumour 
reached  nearly  to  the  umbilicus,  and  completely  filled  the  pelvic  basin.  She 
had  been  seen  by  other  g3-n8ecologists,  who  had  decided  that  though  operation 
was  the  only  course  open,  the  risks  were  so  gi'eat  tliat  it  could  not  be  advised. 
I  told  her  that  at  least  one  woman  out  of  every  ten  operated  upon  would  die 
from  the  operation  itself;  that  I  advised  interference,  seeing  the  certain 
dangers  which  would  arise  if  nothing  were  done  to  relieve  her,  but  that  the 
decision  should  rest  with  herself.     She  resolved  to  have  the  operation. 

The  tumour  (Plate  XLI.)  was  readily  exposed,  and  the  cause  of  its  fixation 
in  the  pelvis  discovered  to  be  adhesions  which  bound  it  deeply  and  posteriorly. 
"^Iien  these  were  freed  with  the  hand,  the  tumour  was  delivered  by  the  heli- 
coid.     The  patient  made  an  excellent  recovery. 

It  is  interesting  to  note  what  a  distinguished  woman  gynaecologist  has  to 
say  in  this  connection.*  '  I  do  not  believe  a  woman  can  have  a  fibroid  tumour, 
however  small,  without  having  direct  and  sympathetic  trouble,  for  the  tumours 
not  only  may  produce  various  uterine  displacements,  with  their  accompanying 
evils  and  distresses,  but  they  encroach  upon  normal  structures,  derange,  change, 
and  destroy  it,  disturb  normal  functions,  are  a  constant  irritation  to  the  organic 
system  of  the  uterus,  and,  by  sympathetic  troubles  and  reflex  irritations,  the 
injuries  they  produce  are  more  than  we  can  measure  or  calculate.  They 
render  the  whole  being  physically  and  morally  incompetent,  nature  is  intolerant 
of  them,  and  the  patients  are  worn  out  by  the  disorders  resulting  from  them.' 

*  Mary  Dixon  Jones,  in  the  Brit.  Gyn.  Jour.,  Feb.  1898. 


454  DISEASES  OF   WOMEN. 

She  farther  contrasts  the  burden  of  a  child  in  utero  in  its  psychical  and 
physiological  effects,  with  those  attendant  upon  the  dead  burden  of  a  fibroma. 
'  No  hope  of  relief,  no  anticipation,  only  a  sickening  prospect,  gloomy  fore- 
bodings, and  the  saddest  possibilities.' 

Dr.  Mary  Scharlieb,  the  distinguished  operating  gynaecologist,  accepts  as 
indications  for  operation  such  present  conditions  as  hsemorrhage,  pain,  pressure 
on  the  bladder,  ureters,  and  rectum,  invalidism,  and  the  possibility  of  future 
degeneration,  and  her  practice  is  in  accord  with  her  expressed  opinion.* 

A.  Martin  says,  'No  one  denies  that,  especially  under  the  influence  of 
some  well-known  iodine  waters,  climacteric  involution,  which  must  be  con- 
sidered as  a  cure,  may  develop  in  a  fateful  and  even  premature  manner ; 
nevertheless,  in  discussing  the  indications  for  operation,  other  points  are 
admittedly  quite  decisive ;  when  the  tumours  are  comparatively  small,  the 
danger  of  interference  is  materially  less,  and,  a  more  important  point,  it  may 
then  be  possible  to  remove  diseased  tissue  only,  and  to  save  a  portion  of  the 
uterus  capable  of  its  functions.  No  one  denies  that  this  way  of  operating  has 
proved  full  of  blessing,  and  as  the  prognosis  of  operation  is  constantly  im- 
proving, the  advances  in  asepsis  and  technique  allow  us  to  hope  that  the 
propriety  of  early  interference,  as  soon  as  good  health  and  capacity  for  work 
are  permanently  disturbed,  will  be  more  and  more  generally  recognized,  for 
there  is  no  other  treatment  of  the  myomatous  uterus  by  which  the  patient 
can  be  protected  from  further  and  more  serious  troubles.^f 

Medium-sized  and  even  small  tumours,  from  their  position  and  nature,  may, 
have  to  be  removed  on  account  of  their  encroachment  on  the  bladder  and  the 
consequences  of  pressui'e,  as  in  a  case  I  have  recently  operated  upon,  in  which 
the  bladder  was  adherent  for  a  considerable  distance  to  the  face  of  the 
tumour.  Extremists  may  say  '  that  all  fibroid  tumours,  large  or  small,  should 
be  removed,  as  they  are  always  a  source  of  danger  and  of  dangerous  possi- 
bilities.' An  axiom  so  comprehensive  few  gynsecologists  will  agree  with, 
even  though  the  enunciators  of  it  quote  in  support  of  their  statement  the  fact 
that  Thomas  Keith  performed  hysterectomy  for  a  uterine  fibroid  that  weighed 
1  lb.,  and  that  A,  Martin  operated  for  a  tumour  the  size  of  an  apple.  It  is 
well  known  how  conservative  in  regard  to  interference  was  that  most  distin- 
guished of  Scottish  gjmsecologists,  Thomas  Keith,  in  his  later  writings  with 
regard  to  hysterectomy,  but  the  mortality  then  was,  as  has  been  well  said, 
nothing  short  of '  fearful.' 

Finally,  it  may  be  permissible  here  to  repeat  what  I  have  else- 
where said  on  this  important  question  : — 

Propriety  of  Operation.^: — '  The  propriety  of  the  operation  has  to  be  deter- 
inined  under  so  many  diverse  conditions  and  circumstances,  that  our  resolve  to 
operate  or  not  must  depend  upon  the  special  features  of  the  individual  case  in 
which  a  decision  has  to  be  arrived  at.  We  have  to  decide  what  are  the  im- 
mediate dangers  attendant  upon  the  tumour  in  question,  whether  it  be  of  such 
a  nature  as  to  ajEford  room  for  alternative  treatment,  more  particularly  when 

*  Brit.  Med.  meeting,  Ipswich,  1900.  t  Berliner  K.  Wclms.,  1902,  No.  19. 

X  '  Practical  Points  in  Gynaecology'  (Author),  3rd  edit.,  1902. 


UTERIXE   XEOPf.ASMS— MYOMA— FiURGICAL    THKATMKM.     -J.-.S 

the  operative  procedures  of  lij^ature  of  tlic  uterine  arteries,  salpingo-oupiiorec- 
toray,  or  myoinertomy  are  alternatives  wliicii  are  not  only  jiistilicMl  l)iit  indi- 
cated. We  inuRt  fairly  jiulge  how  far  the  character,  position,  and  attachments 
of  the  growth  or  growths  influence  the  risk,  raising  it  above  that  whicli  is  ac- 
cepted as  a  fiiir  average  following  from  the  operation  in  cases  wliich  are  not 
of  a  very  exceptional  nature.  In  doing  so,  we  have  to  apportion  as  nearly  as 
we  can  the  internal  and  inherent  dangers  which  are  incidental  to  the  tumour 
itself  in  its  pathological  featin-es,  as  well  as  its  surrounding  complications,  those 
present  at  the  time,  or  likely  to  follow  its  further  gi'owth  and  development. 

'  The  lesson  drawn  from  the  case  of  a  woman  who  determines  to  bear  with 
her  tumour,  and  put  up  with  the  necessary  discomfort,  or  endure  chronic 
invalidism,  has  no  bearing  on  that  of  a  woman  who  has  domestic  or  other 
duties  to  perform  in  order  to  support  herself  or  family,  and  has  to  earn  her 
li\'ing.  If  the  woman  be  a  free  agent,  as  she  should  be,  it  is  our  duty  to 
assist  her  to  arrive  at  a  conclusion  based  upon  an  intelligent  and  fairl}'  accurate 
view  of  the  reasons  for  and  against  interference,  placing  before  her  the  dangers 
of  expectancy  as  compared  with  those  of  whatever  operation  we  advise,  lean- 
ing rather  to  an  exaggeration  than  an  underrating  of  the  latter.  This  of 
course  refers  only  to  cases  in  which  necessit}^  and  urgency  do  not  call  for 
the  unqualified  advice  of  immediate  operation.  Should  we  coimsel  postpone- 
ment, at  least  in  a  large  number  of  cases  the  woman  should  clearly  imder- 
stand  that  she  undertakes  the  responsibility  for  the  increased  dangers  and 
possible  complications  resulting  from  procrastination.  Only  a  comparative 
few  of  those  who  do  not  sufiFer  from  serious  complications  of  the  tumour  can 
be  said  not  to  be  more  or  less  invalids,  and  we  must  recollect  this  when 
advising  in  the  case  of  one  whose  means  are  not  such  as  to  afford  her 
opportunity  for  palliative  treatment  and  rest. 

'  By  clinical  observation  and  examination,  the  presence  of  the  gi'eat  majority 
of  these  complications  may  be  ascertained,  and  this  knowledge  will  largel}' 
determine  us  in  our  prognosis  and  decision  as  to  operation.  A  tumonr  in 
which  there  is  no  evidence  of  any  serious  degenerative  change,  which  is 
not  complicated  by  gross  changes  in  the  adnexa,  which  is  causing  no  serious 
obstruction  to  the  bowel  or  displacement  of  the  bladder  with  incontinence 
or  distress,  where  neither  peritoneal  nor  ascitic  complications  are  present, 
and  the  rapidity  or  the  size  of  the  growth  has  not  to  be  considered,  will 
certainly  not  demand  interference.  Such  a  tumour  can  have  but  little 
influence  on  the  general  health  of  a  woman;  yet  there  are  some  women  of 
the  neurasthenic  and  neurotic  temperaments  of  whom  this  cannot  truthfully 
be  said.' 


CHAPTER   XXV. 


UTERINE    NEOPLASMS— MYOMA   (continued)— 
SURGICAL   TREATMENT. 

Ligation  of  the  Uterine  and  Ovarian  Arteries. 

As  a  substitute  both  for  hysterectomy  and  oophorectomy,  several 
surgeons,  notably  Ptobinson  and  Martin,  of  Chicago,  have  ligated 
the  uterine  and  ovarian  vessels  to  check  haemorrhage  and  induce 
atrophy  of  the  tumour. 

In  Martin's  operation,  the  cervix,  liaviag  been  well  exposed  by  retractors, 
is  transfixed  -with  a  strong  silk  ligature,  any  secretion  from  the  uterine  canal 

being  restrained  by  a  tampon  of 
gauze,  over  which  the  ligature  is 
tied.  The  uterus  having  been 
drawn  down,  the  left  vaginal  vault 
is  exposed  (Fig.  300),  and  the 
mucous  membrane  at  the  utero- 
vaginal junction  is  incised  with 
cui-ved,  scissors ;  one  blade  is  then 
entered,  and  a  curved  incision 
about  2  inches  in  length  is  carried 
over  the  broad  ligament  at  right 
angles  to  it.  An  index-finger  of 
each  hand  is  now  introduced  (Fig. 
301),  and  the  vaginal  tissue  is 
detached  from  the  broad  hgament 
in  front  of  the  bladder  for  a  space 
of  2  inches  in  height,  and  tlie  same 
distance  to  the  side.  In  doing 
this  the  ureter  is  pushed  out  of 
reach.  The  same  plan  is  adopted 
posteriorly.  The  peritoneum  is  not 
injured.  The  base  of  the  broad 
ligament  for  a  distance  of  1  inch 
to  1^-  inches  from  the  uterus  is 
grasped  in  the  manner  shown  in 


Fig.  300.— Shows  Incision  over  Left 
Beoad  Ligament.    (Maetin.) 


the  drawing  (Fig.  302).  Finally,  a  needle  threaded  with  No.  12  braided  silk, 
guided  by  the  index-finger,  is  carried  behind  the  broad  ligament  clear  of  all 
pulsating  vessels  and  made  to  penetrate  it. 


rTi:nixE  xEorr.A.^M.'^— myoma— sunciCAL  treatment,   atu 

Thus  the  base  of  the  broad  hgament  is  ligatured  firmly  a  full  inch  from  the 
utems.  The  ligature  is  cut  short  and  allowed  to  retract.  The  opjiosite 
side  having  been  similarly  dealt  with,  both  vaginal  incisions  are  carefully 
closed  with  catgut,  thus  com- 
pletely burying  the  silk.  The 
cervical  handling-string   is  with- 


FiG.  301. — Separation"  of  the 
Broad  Ligament  with  the 
Fingers. 


Fig.  302. — Grasping  the  Base  of 
THE  Broad  Ligament. 


drawn,  and  the  vagina  packed  with  iodoform  gauze.  The  subsequent  treat- 
ment is  simple.  Thorough  antisepsis  being  maintained,  the  vaginal  wound 
is  healed  in  about  a  week. 


Fig.  303. — Ligaturing  Base  of  Broad  Ligament;  Vaginal  Incision  closed. 


Salpingo-Oophorectomy  for  Fibroid  Tumours. 

The  indications  for  removal  of  the  uterine  appendages  and  the 
details  of  the  operation  for  disease  of  the  adnexa  will  be  referred 
to  when  dealing  with  affections  of  the  Fallopian  tube  and  ovary. 
(See  chapter  on  Affections  of  the  Fallopian  Tubes  and  Ovaries.) 

I  take  this  oppoi-tunity  of  objecting  to  the  use  of  the  term  •  castration.'  In 
the  case  of  fibroid  tumours,  the  organs  that  are  removed  may  be  healthy,  for 
the  operation  is  performed  to  bring  about  the  premature  change  of  life.     Yet 


458  DISEASES   OF    WOMEN. 

even  in  this  instance  I  think  it  preferable  to  adhere  to  the  term  '  salpingo-oopho- 
rectomy.'  In  all  other  cases  in  which  we  advise  removal  of  the  appendages, 
we  do  so  for  diseased  conditions  which  either  directly  or  indirectly  affect  the 
health  or  threaten  the  life  of  the  woman.  In  the  instance  of  fibroids,  the 
removal  of  the  appendages  is  undertaken  for  conditions  which  would,  in  the 
vast  majority  of  those  who  suffer  from  them,  render  conception  impossible. 
In  most  of  the  cases  there  are  pathological  conditions  of  the  appendages 
associated  with  these  gi'owths.  The  term  '  castration  '  being  allied  in  the 
public  mind  with  the  deliberate  mutilation  of  the  heaWiy  organs  of  generation 
for  the  sole  purpose  of  unsexing  the  man  or  animal  on  whom  it  is  performed, 
the  use  of  it  in  describing  what  is  in  its  ultimate  aim  and  object  a  truly 
conservative  step,  the  cure  or  arrest  of  disease,  is  misleading.  It  tends  to 
prejudice  an  operative  step  which  is,  when  rightly  taken,  a  most  valuable 
gynaecological  procedure. 

It  is  interesting  to  recall  Battey's  original  statement  to  the  American 
Congress  of  1881  iviiJi  regard  to  ooplwrectomy  for  growing  or  bleeding 
fibroids  : — 

'  Perhaps  no  safer  rule  can  be  laid  down  to-day  by  which  one  may 
determine  in  any  given  case  the  propriety  of  the  operation,  than  by 
ashing  himself  three  questions,  namely — 1.  Is  this  a  grave  case?  2.  Is 
it  incurable  by  any  of  the  resources  of  the  art  short  of  the  change  of 
life  ?  3.  Is  it  curable  by  the  change  of  life  ?  If  all  three  of  these 
questions  can  be  answered  affirmatively,  the  case  is  a  proper  one  ;  but  if 
not,  the  operation  is  not  to  be  justified,'' 

Since  then,  and  more  especially  of  late,  very  different  views  have 
been  held  by  leading  gynaecologists  on  the  value  of  salpingo- 
0(iphorectomy  for  bleeding  fibroids. 

It  is  difficult  to  define  the  kind  of  uterine  growth  which  it  is 
right  to  treat  by  removal  of  the  adnexa.  This  arises  from  the  fact 
that  the  principal  indications  for  the  operation,  viz.  size  and  rapidity 
of  growth  and  haemorrhage,  have  associated  with  them  in  different 
women  such  widely  varying  conditions,  both  touching  the  tumour 
itself  and  the  patient's  health  and  circumstances,  that  no  rule  can 
be  laid  down.  The  involvement  of  other  organs,  the  nature  of  the 
tumour,  and  the  symptoms  directly  dependent  on  its  size,  the 
patient's  age,  and  the  possibility  of  pregnancy,  are  among  the  most 
prominent  facts  which  must  influence  our  decision.  In  favour  of 
the  operation  is  the  diminution  of  risk,  and  the  fairly  large  propor- 
tion of  cures.  Against  it  are  the  number  of  cases  in  which  bleeding 
continues,  and  that  in  some  instances  myomata  grow  more  rapidly 
after  the  operation. 

The  indications  and   contra-indications  for  the   performance  of 


UTER TNE  NEOPLA F^MS— MYOMA— S UBG  JCA  L    TREA  TMEN T.     450 

this  operation  for  the  removal  of  a  myoma  have  been  already 
given.  Considerable  diversity  of  opinion  still  exists  as  to  the 
position  this  operative  step  should  take  in  the  treatment  of  a 
myoma.  There  are,  however,  certain  cases  in  which  it  is  not  only 
justifiable,  but  imperative,  to  give  the  patient  the  chance  of  relief 
by  this  means,  even  though,  as  Edge  well  puts  it,  '  we  are  seeking 
immediate  safety  rather  than  theoretical  perfection  and  thoroughness.' 
The  results  of  the  operation  show  that  in  at  least  eighty  per  cent, 
of  the  cases  the  menopause  is  brought  about,  and  that,  in  ninety 
per  cent,  of  tlwroughlij  completed  operations,  shrinking  in  varying 
degrees  occurs,  while  the  general  health  of  the  patient  is  improved. 
It  must  also  be  borne  in  mind  that  in  a  large  proportion  of  patients 
suflering  from  fibroid  tumour  of  the  uterus  there  are  pathological 
conditions  of  the  ovaries  and  tubes  associated  with  it. 

Operation  of  Salpingo-Oophorectomy  (Abdominal) — Position  of 
the  Adnexa  and  Appendix. 

Having  decided  to  perform  the  operation  of  salpingo-oophorectomy, 
we  proceed  to  make  a  careful  examination,  both  abdominal  and 
vaginal,  of  the  relations  of  the  tumour,  and  to  define  as  far  as 
possible  the  existence  of  adhesions  and  the  position  of  the  adnexa. 
It  must  be  remembered  that  this  varies  in  cases  of  myoma  according 
to  the  mode  of  growth  of  the  tumour,  the  adnexa  being  displaced  in 
different  directions.  Sometimes  they  are  found  at  the  summit  of 
the  tumoui',  at  others  at  the  lower  part  of  it,  or  again,  behind  it. 
Also  they  may  be  fixed  by  their  adhesions  to  the  uterus  or  the 
pelvic  structures ;  and  oftentimes  such  adhesions  are  both  extensive 
and  strong,  the  ovaries  and  tubes  being  embedded  in  a  mass  of 
adhesive  bands,  which  half  conceal  them  from  view  with  new  tissue 
formation.  There  may,  too,  be  solid  tumours  of  the  ovary,  or  old 
suppurative  conditions  both  of  the  tubes  and  the  ovaries.  Under 
anaesthesia  we  can  frequently  determine  beforehand  the  presence  of 
such  conditions.  On  the  other  hand,  the  adnexa  are  frequently 
readily  accessible,  being  carried  upwards  by  the  tumour.  It  is  well 
also  to  remember  that  the  appendix  may  be  involved  through  old 
adhesions,  and  its  position  altered,  being  attached  to  the  tumour, 
or  to  some  portion  of  the  right  adnexa,  while  the  sigmoid  flexure  is 
likewise  displaced  or  attached  at  the  left  side.  Omental  adhesions 
are  not  uncommon. 

Operation. ^ — The  patient  is  prepared  as  usual  for  coeliotomy,  and, 
if  obtainable,  a  table  capable  of  being  placed  in  the  Trendelenburg 


460  DISEASES   OF    WOMEN. 

position  is  used.  It  is  wise  to  make  a  somewhat  longer  incision 
than  that  usually  required,  and  it  may  be  necessary  to  enlarge  this 
still  further  if  any  of  the  difficulties  enumerated  have  to  be  met. 
Small  retractors  should  then  be  used  to  hold  the  margins  of  the 
wound  well  asunder.  In  making  the  abdominal  incision,  care  has 
to  be  taken  lest  any  portion  of  bowel  should  lie  superficially  over  the 
tumour.  Before  opening  the  peritoneum,  all  bleeding  points  are 
secured  by  pressure  forceps,  and  here  those  of  Zweifel  are  valuable 
in  quickly  and  permanently  checking  the  bleeding  from  small 
vessels.  Search  is  then  made  for  the  adnesa  of  one  side,  the  broad 
ligament  acting  as  a  guide  to  the  tube  and  ovary,  stretching  out- 
wards at  either  side  from  the  fundus  of  the  uterus.  If  these  be 
free,  they  may  at  once  be  drawn  outside  the  wound.  Should  there 
be  fluid  present  in  either  tube  or  ovary,  its  escape  has  to  be  guarded 
against  by  means  of  a  piece  of  sterilized  gauze,  which  is  nipped  round 
the  adnexa  by  a  pressure  forceps.  The  fluid  can  then  be  evacuated 
by  a  small  trocar  or  aspirator,  at  the  same  time  that  flat  sterilized 
protectors  are  used  to  protect  the  peritoneum  and  intestine.  Small 
squares  of  muslin  are  easily  tucked  in,  and  spread  over  the  intestine, 
one  protruding  end  being  ahvays  caught  in  a  catch  forceps.  It  is 
essential  to  expose  the  entire  Fallopian  tube,  as  no  portion  of  tube 
or  ovary  should  be  left.  A  portion  of  the  broad  ligament  devoid  of 
vessels  is  now  pierced  with  a  Deschamp's  needle,  carrying  the  loop 
of  gut  through.  The  needle  is  withdrawn.  The  loop  is  divided, 
and  the  adnexa  are  securely  ligatured  oif.  When  removing  them 
with  the  scissors,  sufficient  peritoneum  is  left  to  cover  the  pedicle. 
A  light  clamp  is  now  passed  below  the  pedicle,  so  as  to  secure  it. 
The  peritoneum  is  reflected  back,  and  a  few  pieces  of  thin  gut  secure 
separately  the  ovarian  vessels.  The  peritoneum  is  then  carefully 
adjusted  over  the  surface  of  the  stump  by  a  continuous  suture  of 
thin  cumol  gut,  so  as  to  leave  no  raw  surface.  If  the  method  of 
Tait  be  followed,  a  loop  of  double  ligature  is  passed  through  the 
centre  of  the  broad  ligament,  avoiding  the  vessels.  The  loop  is  then 
turned  back  so  as  to  include  both  the  ovary  and  tube  in  the  two 
loops  thus  formed.  One  free  end  is  next  passed  through  the  re- 
turned loop,  both  ends  are  now  drawn  tightly,  tied,  and  then  cut 
off  (the  Staffordshire  knot),  or  the  loop  is  passed  through  the  pedicle 
and  the  needle  is  withdrawn.  The  loop  is  now  cut,  and  either  half 
of  the  pedicle  is  tied,  the  several  ends  are  again  tied  tightly  in 
figure  of  eight  fashion,  and  the  pedicle  is  cut.  The  opposite  ovary 
and  tube  are  now  treated  in  the  same  manner.     Dabs,  wrung  out  of 


UTEBINE  NEOPLASMS— M yoM A—  SUEGJCAL    TREATMENT.     461 

warm  formalin  solution,  are  carried  by  long  clamp  forceps  into  the 
pelvic  cavity  and  the  pouch  of  Douglas,  which  are  thoroughly 
cleared  of  all  remains  of  blood.  The  abdominal  toilet  is  then  com- 
pleted, peritoneum,  muscle  and  fascia,  and  skin. 

Howard  Kelly  insists  that  the  point  of  selection  for  the  removal  of  the 
adnexa  is  at  the  infiuulibulo-i^elvic  margin,  where  nothing  is  to  be  found 
between  the  layers  of  the  broad  ligament,  and  there  is  therefore  no  danger  of 
wounding  any  large  venous  vessel.  Here  tlie  loop  of  suture  is  cut  when 
passed,  one  half  being  tied  over  the  in  fun  dibulo -pelvic  ligament,  and  the  other 
close  to  the  uterine  horn.  When  the  tube  and  ovary  are  removed,  one 
ligature  is  drawn  towards  the  pelvic  wall,  and  the  other  to  the  cornu  of  the 
uterus,  while  the  two  laj^ers  of  the  broad  ligament  lie  parallel  and  in  close 
apposition.  Hence,  suturing  is  unnecessary,  and  there  is  no  space  for  the 
strangulation  of  any  loop  of  bowel,  nor  is  there  any  pressure  on  the  rectum. 

Simple  as  this  operation  is  in  the  majority  of  cases,  it  becomes 
quite  a  ditlerent  matter  if  the  surgeon  has  to  deal  with  unexpected 
dithculties  in  the  pelvis.  There  may  be  displacement  of  the  adnexa 
through  the  presence  of  a  uterine  or  intra-ligamentary  fibroid ;  also, 
adhesions  most  difficult  to  detach  may  be  encountered.  Again,  there 
may  be  found  a  cyst  distended  with  serum,  blood,  or  pus,  to  the 
point  of  rupture,  and  this  may  be  fixed  by  adhesion  to  the  bladder 
or  bowel.  The  safe  rules  to  adopt  are,  to  avoid  all  hurry,  to  deal 
carefully  with  adhesions,  to  ligature  or  control  by  forceps  and 
ligature  all  bleeding  as  we  proceed,  and  to  safeguard  the  operation 
throughout  by  the  most  thorough  asepsis. 

Bovee*  enters  a  strong  plea  against  removal  of  the  Fallopian 
tube  and  ovary  en  masse,  and  advocates  the  removal  of  the  ovary 
and  tube  thus  : — 

A  small  clamp  is  placed  on  the  infundibulo-pelvic  ligament  close 
to  the  fimbriated  end  of  the  tube,  and  including  only  the  part  of 
the  ligament  containing  the  blood  vessels ;  another  is  placed  on  the 
Fallopian  tube  close  to  the  uterus,  but  not  including  the  trunk  of 
the  utero-ovarian  vessels ;  a  third  is  placed  on  the  ovarian  ligament. 
Then  the  tube  is  carefully  dissected  from  the  top  of  the  broad 
ligament  up  to  the  forceps  clamping  it,  the  wound  closed  by  a  con- 
tinuous over  and  over  suture  of  catgut  and  the  clamp  removed.  In 
doing  this,  care  is  needed  to  coaptate  properly  the  cut  edges  of  the 
peritoneum.  Then  the  ovary  is  carefully  separated  from  the  broad 
ligament  and  the  ovarian  ligament  severed  just  outside  the  forceps. 
This  wound  is  also  closed  by  the  same  kind  of  suture  and  the  clamp 
removed.  We  have  left  the  short  stump  of  the  uterine  end  of  the 
*  Amer.  Gijn.,  June,  1903. 


462  DISEASES   OF    WOMEN. 

tube.  Traction  on  the  clamp  puts  the  stump  on  the  stretch,  and  it 
is  cut  off  within  the  uterine  tissue.  The  wound  is  closed  similarly 
to  the  others,  and  the  work  is  finished.  This  method  does  not 
include  removal  of  any  of  the  broad  ligament,  does  not  shorten  it, 
is  accompanied  with  a  minimum  amount  of  traumatism,  insures 
complete  ablation  of  the  appendages,  and  prevents  connection 
between  the  uterine  and  peritoneal  cavities. 

This  doubtless  is  an  ideal  method,  but  personally  I  have  never 
found  any  ill  consequences  follow  from  the  technique  described  in 
the  text.  It  is  impossible  to  have  any  haemorrhage  if  the  pedicles 
be  sewn  over  and  covered  carefully  with  peritoneum. 

Should  adhesions  be  present,  these  must  be  carefully  separated, 
working  with  the  finger  a  small  dossil  of  gauze  fixed  in  a  clamp 
forceps.  More  resistant  connecting  bands  are  ligatured  and  divided, 
the  ovary  being  raised  from  any  bed  of  plastic  material  in  which  it 
may  be  embedded,  and  care  being  taken  to  avoid  injury  to  the 
bladder  or  rectum  while  this  is  being  done.  Should  pus  sacs  or 
cysts  be  unavoidably  opened,  and  pus  or  cystic  contents  escape  into 
the  pelvic  or  abdominal  cavity,  it  is  my  practice  to  resort  to  repeated 
mopping  out  of  the  cavity  with  moist  dabs  of  sterilized  gauze  soaked 
in  and  partly  squeezed  out  of  weak  formalin  solution.  This  must 
be  done  gently,  so  as  not  to  tear  or  injure  the  omentum,  the  peri- 
toneum, or  the  bowel.     No  drainage  is  required,  as  a  rule. 

Operative  procedures  on  the  pelvic  viscera  and  the  ever-varying 
and  complex  conditions  found  on  opening  the  abdomen,  admit 
practically  of  no  fixed  rule  in  dealing  with  them.  The  true  surgical 
artist  is  he  who,  while  conforming  to  broad  and  unalterable  surgical 
principles,  deals  with  each  case  and  its  complications  as  it  presents 
itself  to  him  at  the  time  of  operation,  his  resources  Limited  by  no 
rigid  theoretical  consideration,  and-  his  hand  not  held  by  any 
authoritative  ipse  dixit.  Through  such  freedom  of  action  can  we 
alone  hope  for  progress,  and  in  no  part  of  the  human  body  is  such 
liberty  demanded  more  than  it  is  in  the  surgery  of  the  female 
organs  of  generation.  It  were  well  to  bear  this  in  mind  in  discussions, 
often  futile,  on  this  or  that  method  of  procedure,  and  in  disputations 
over  steps  of  operations,  the  bearings  of  which  vanish  in  actual 
practice,  when  face  to  face  with  unexpected  and  novel  difficulties, 
where  the  surgeon  has  to  fall  back  on  his  individual  judgment  and 
surgical  instinct  for  guidance. 

Management  of  the  Pedicle. — Whatever  method  be  adopted,  whether  that 
of  drawing  the  peritoneum  over  the  pedicle  and  suturing  it,  and  thus  hiding 


UTEEIXE  NEOPLAtiMS— MYOMA— SUliaiCAL    TliEATMENT.     463 

it  from  view,  or  dissecting  a  collar  from  the  pedicle  and  suturing  it  over  the 
stump,  or  covering  it  witli  the  posterior  surfrice  of  the  broad  ligament,  there 
can  be  no  doubt  that  if  we  want  to  avoid  intestinal  complications,  adhesions, 
and  reflex  nerve  symptoms  and  subsequent  complications  during  pregnancy, 
the  pedicle  should  always  be  carefully  covered  before  it  is  dropped  into  the 
abdominal  cavity. 

Edge,  quoting  from  Bumm,*  thus  classifies  the  different  methods  of  cover- 
ing the  pedicle  :  (a)  When  the  area  of  the  pedicle  is  small,  Condamin  f 
advised  that  the  peritoneum  should  be  drawn  over  it  and  sutured.  In  this 
way  the  pedicle  is  completely  hidden,  (i)  Kreutzmann  %  brings  the  tumour 
out,  and  then  dissects  a  collar  from  the  pedicle  down  to  the  point  of  section. 
He  divides  the  pedicle,  picking  up  vessels  one  by  one,  and  removes  the 
tumour,  then  ties  the  vessels  and  sutures  the  collar  of  peritoneum  over  the 
end  of  the  stump,  (c)  Eosen  §  seizes  the  pedicle  with  one  or  two  pairs  of 
forceps  and  cuts  above  them  ;  he  ties  the  larger  vessels,  removes  the  forceps 
and  ligatures  any  bleeding  points.  He  draws  the  peritoneal  sheath  over  the 
pedicle  and  ligatures  it.  The  pedicle  is  thus  provided  with  a  peritoneal 
sheath,  {d)  A  fourth  method  consists  in  ligaturing  the  pedicle  as  usual.  A 
suture  is  then  passed  immediately  below  this  primary  ligature  and  tied,  so 
that  its  two  ends  are  in  front.  With  a  Deschamp  needle  the  two  ends  are 
separately  drawn  through  the  broad  ligament  and  tied  on  the  front  of  this. 
The  pedicle  is  thus  pulled  into,  and  adheres  to,  the  posterior  surface  of  the 
broad  ligament. 

Bisection  of  the  Uterus  in  Hystero-salpingo-odphorectomy. 

The  principle  of  bisection  of  the  uterus,  both  in  the  removal  of 
adnexa  in  which  there  have  been  suppurative  conditions  leading  to 
extensive  adhesions,  at  one  or  both  sides,  and  in  tumours  compli- 
cated by  adnexal  abscesses  and  adhesions,  has  been  accepted  for  a 
considerable  time.  I  saw  the  Landaus  adopting  it  in  Berlin  in 
1897,  Doyen  in  Paris  the  year  after,  and  Schauta  in  Vienna  in  1899. 
This  was  in  vaginal  operations  for  adnexal,  cancerous,  and  other 
tumours,  also  in  some  myomata. 

Faure  (Paris)  first  adopted  the  same  principle  in  abdominal 
cceliotomy  for  pelvic  suppurations,  and  carcinoma  of  the  uterus  and 
adnexa.  He  carried  the  bisection  from  above  downwards,  through 
both  the  anterior  and  posterior  surfaces  of  the  uterus,  first  securing 
the  uterine  arteries  by  carrying  the  section  outwards  towards  the 
broad  ligament.  The  principle  was  also  followed  in  the  removal  of 
certain  myomata,  both  uterine  and  intra-ligamentary,  which  were 
firmly  held  down  in  the  pelvic  cavity  by  adhesion,  and  in  intra- 
ligamentary  growths  of  the  broad  ligaments,  as  well  as  in  those  in 

*  International  Congress,  1800.  f  Revue  Med.,  1803. 

X  Amer.  Jour.  Ohstet.,  1806.  §  Przeglad  Leharaki,  Kracocia,  1000. 


464  DISEASES   OF    WOMEN. 


which  the  myoma  lies  under  the  vesical  peritoneal  reflection,  and 
more  especially  in  such  cases  in  which  diseased  states  of  the  adnexa 
complicate  the  tumour. 

However,  quite  independently  of  Faure,  Howard  Kelly  * 
practised  the  same  abdominal  method  in  certain  complicated  cases 
of  myoma,  and  also  in  the  removal  of  adnexal  masses  consequent 
upon  extensive  inflammatory  and  suppurative  states.  He  pursued 
the  same  plan  in  cases  of  cervical  myomata  which  pushed  the  bladder 
up  out  of  the  pelvis  with  the  utero-vesical  peritoneum ;  clamping 
the  uterine  and  ovarian  vessels  at  either  side,  he  divided  the  uterus 
from  above  down,  removing  either  half,  closing  the  bed  of  the 
tumour  by  buried  sutures,  and  covering  the  wound  by  uniting  the 
vesical  and  the  posterior  peritoneum  with  sutures.  He  urges  this 
method  in  the  case  of  fibroid  tumours  of  large  size  filling  the  pelvis 
and  raising  with  its  growth  the  uterine  and  ovarian  vessels,  in  con- 
sequence of  which  displacement  these  vessels  cannot  be  tied  en 
masse.  Should  the  colon  or  rectum  be  intimately  attached  to  the 
tumour,  he  advocates  the  plan  of  leaving  a  very  thin  layer  of  the 
tumour  upon  the  bowel  rather  than  endanger  the  latter  by  removing 
it.f  He  takes  the  following  condition  as  an  indication  of  a  modi- 
fication of  this  method  :  '  Given  a  uterus  with  dense  lateral  inflam- 
mation binding  down  the  adnexa  beyond  the  possibility  of  liberation 
by  fingers  alone,  and  added  to  this  adhesions  of  the  bowel  and  of 
the  bladder,  almost  or  quite  burying  the  uterus,'  and  he  proceeds 
thus  : — 

The  neck  of  the  uterus  having  been  grasped  by  a  curved  vul- 
sellum,  introduced  through  the  vagina,  and  the  pelvis  having 
been  elevated,  the  abdomen  is  opened  freely  in  the  middle  line. 
By  the  vulsellum  in  the  vagina  the  cervix  is  pushed  as  high  as  pos- 
sible in  the  direction  of  the  incision  until  it  projects  behind  the 
symphisis.  The  bladder  is  now  freed  and  pushed  down.  The 
supra-vaginal  cervix  is  next  grasped  between  the  two  vulsellum 
forceps,  and  divided  transversely.  By  drawing  the  upper  portion 
of  the  now  divided  neck  well  up  with  Museau  forceps,  the  uterine 
arteries  are  exposed  and  clamped.  Forceps  are  next  applied  on 
either  side  of  the  severed  cervix,  and  the  uterus  is  divided  from 
below  upwards  with  careful  regard  to  the  rectum,  and  any  adhe- 
sions, '  if  need  be,  leaving  small  areas  of  uterine  tissue  adherent  to 

*  Amer.  Jour.  Obstet.,  Aug.,  1900  ;  Johns  Sopliins  Hospital  Bulletin,  1900, 
p.  56,  xi. 

t  See  Johns  Hophins  Bulletin,  March,  1900,  Jan.,  1901. 


UTEIUNE   SEOPLAfiMS— MYOMA— SURGICAL    TUEATMEXT.     4G5 


the  bowel.'    Each  half  of  the  uterus  is  then  removed,  after  which 
the  ovarian  vessels  are  ligatured,  and  there  is 
ample  room  to  free  and  remove  the  adherent 
adnexa.* 

Vaginal  Myomectomy. — This  operation  by 
enucleation  is  more  specially  adapted  for  sub- 
mucous libroids  which  protrude  in  the  direc- 
tion of  the  cavity  of  the  uterus,  being 
embedded  in  the  muscular  stroma.  Enuc- 
leation is  by  many  considered  justifiable 
under  these  circumstances,  even  when  the 
tumour  has  attained  to  the  size  of  the  head 
of  the  ftetus  at  full  term. 

The  step  of  morcellement  has  been  added  to 
that  of  enucleation,  to  facilitate  further  the 
removal  of  the  mass  in  cases  in  which  it  is 
not  possible  to  shell  it  out  and  deliver  it  in 
its  entirety.  Obviously,  the  character  of  the 
operation  must  vary  according  to  the  size  and 
depth  of  the  tumour.  The  patient  is  tho- 
roughly prepared  as  for  vaginal  hysterectomy. 
It  is  necessary  to  have  at  least  three  assistants. 
One  pushes  the  uterus  well  down ;  one 
at  either  side  of  the  operator  takes  charge  of 
the  retractors,  the  douche,  or  the  vaginal 
douche  retractor ;  and  both  mutually  assist 
in  the  manipulation  of  the  uterus  in  securing 
haemostasis  and  ligaturing. 

The  steps  of  the  vaginal  operation  consist 
of  (a)  preliminary  incision  as  far  as  the 
vaginal  attachment,  having  first  ligatui'ed 
the  lower  branches  of  the  uterine  vessels. 
(See  Ligation  of  the  Uterine  Arteries,  p. 
256). 

(h)  The  second  step  consists  in  the  com- 
plete depression  of  the  tumour  by  strong 
fixing  forceps,  and  the  opening  of  the  capsule. 
This  is  done  with  scissors,  bistoury,  or  the 
nail  of  the  operator,  (c)  The  third  step 
consists  in  the  separation  of  the  tumour  with 

*  See  Figs.  256,  256.^,  pp.  368,  369. 

2   H 


Fig.  30i. — Esucleatok 
FOR  Shelling  out  the 
Tumour. 

The  serrated  end  is  the 
latest  suggestion  of 
Kelly. 


466  DISEASES   OF   W02IEX. 

the  finger,  spatula,  or  the  enucleator  of  Kelly,  assisted  possibly  by 
the  scissors.  After  this  [d)  the  tumour  is  extracted,  as  is  done  in 
the  case  of  a  polypus.  The  gaping  wound  is  trimmed  of  any  torn 
portions  of  mucous  membrane  which  remain,  and  is  thoroughly 
irrigated  with  hot  water.  Search  is  now  made  for  any  small 
myomata,  which  must  be  in  turn  enucleated  by  aid  of  the  scissors 
or  enucleator.  Finally,  the  cavity  is  tamponed  with  sterilized 
iodoform  gauze,  and  a  subcutaneous  injection  of  ergotine  is  given 
to  promote  uterine  contraction. 

The  immediate  dangers  of  the  operation  are  haemorrhage,  per- 
foration of  the  uterine  wall,  and  possible  inversion  of  the  uterus 
during  traction  ;  the  more  remote  are  embolism,  thrombosis,  peri- 
tonitis, and  septicaemia.  All  these  dangers  are  now  diminished  in 
view  of  a  scrupulous  aseptic  technique.  It  may  be  necessary  to 
divide  the  vaginal  wall  posteriorly,  as  well  as  the  uterus,  and  occa- 
sionally also  the  anterior  cul-de-sac.  Where  the  division  of  the 
cervix  runs  up  to  the  fundus,  the  peritoneal  cavity  has,  in  some 
cases,  to  be  opened.  Should  this  happen,  it  is  better  not  to  close 
it  with  sutures,  but  let  the  edges  fall  together.  There  is  less  chance 
of  after  trouble.  At  the  same  time  it  is  always  best  to  avoid 
injuring  the  peritoneum  if  possible,  and  to  push  it  up  cautiously 
both  anteriorly  and  posteriorly  should  it  be  necessary  to  carry  the 
incision  through  both  walls  of  the  uterus. 

Enucleation  by  Coeliotomy  of  Large  Interstitial  Myomata. — 
Spencer  Wells  was  one  of  the  first  operators  who  performed  this 
operation.  Subsequently  A.  Martin,  Spiegelberg,  and  others  largely 
practised  it. 

If  the  operation  of  complete  enucleation  in  the  case  of  a  large 
tumour  be  performed  by  cceliotomy,  a  temporary  elastic  ligature  or 
the  rope  of  Tait  is  carried  round  the  body  of  the  uterus,  below  the 
growth,  which  is  then  opened  through  its  capsule.  A  V-shaped  or 
circular  incision  is  made  over  the  most  prominent  portion  of  the 
tumour,  which  is  then  enucleated.  The  peritoneal  flaps  are  trimmed 
for  accurate  adaptation,  buried  sutures  are  placed  from  below 
upwards,  approximating  the  uterine  tissues,  and,  finally,  the  peri- 
toneal surfaces  are  united  by  interrupted  sutures.  If  the  uterine 
cavity  be  opened,  the  mucous  membrane  is  sutured  separately. 
Drainage  is  maintained  by  the  vagina  (Martin),  or  by  the  abdominal 
wound  (Hegar). 

William  Alexander  does  not  hesitate  to  remove  large   myomata   by  the 
vagina,  opening  ujd   the   anterior  and   posterior  peritoneal  folds.     He   also 


UTERINE   NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     ACu 

strongly  advocates  enucleation  by  abdominal  coeliotoray.     His  method  con- 
sists of — 

1.  The  enucleation  of  all  the  tumours  through  one  longitudinal  opening  in 
the  fundus  uteri. 

2.  Packing  the  cavities  whence  the  tumours  have  been  removed  with 
aseptic  or  antiseptic  gauze,  and  stitching  uj)  the  wound  in  the  uterus  with 
catgut  sutures,  leaving  the  end  of  one  long  strip  of  gauze  to  emerge  from 
the  lower  end  of  the  uterine  wound,  and  to  reach  the  surface  of  the  abdomen 
through  the  lower  angle  of  the  cceliotomy  wound. 

3.  Fixing  the  uterus  temporarily  to  the  abdominal  wall  by  a  single  silk- 
worm-gut suture  tied  on  the  surface  of  the  abdomen. 

In  all  cases  we  must  endeavour  to  avoid  opening  the  uterine  cavity. 

Haemorrhage  is  prevented  and  drainage  is  secured  by  the  gauze,  and  oozing 
from  the  uterine  wound  is  arrested  by  the  pressure  of  the  uterus  against  the 
painetal  peritoneum. 


Fig. 


30.3. — FlBKU3ITu31ATA    SCCCESSFCLLT    ]:;NXCLEATKD    FKOM    A    PaTIEST    BY 

Alexander's  ABDionvAL  Cceliotomy. 


The  packing  is  removed  at  the  end  of  forty-eight  hours,  and  the 
silkworm-gut  suture  at  the  end  of  fourteen  days. 


468  DISEASES   OF    WOMEN. 

Should  the  uterine  cavity  be  opened,  it  must  be  drained  by  a 
glass  tube  from  below. 

Indications  for  Myomectomy. — Howard  Kelly  says  that  myo- 
mectomy should  always  be  preferred  to  supra- vaginal  or  pan-hyste- 
rectomy in  a  young  woman,  when  no  complications  exist  to  interfere 
with  the  operation,  and  where  the  uterus  is  not  larger  than  a  six 
months'  pregnancy.  He  thus  categorically  classifies  the  cases  suit- 
able for  abdominal  myomectomy :  .(1)  Pediculated  myomata,  after 
the  removal  of  which  we  can  preserve  a  normal  uterus.  (2)  All 
interstitial  or  subsei'ous  myomata  which  are  well  defined  in  relation 
to  the  body  of  the  uterus,  whether  single  or  multiple.  (3)  Multiple 
small  myomata.  (4)  Broad  ligament  myomata.  (5)  A  myoma 
localized  at  one  cornu  of  the  uterus.  (6)  A  submucous  myoma  too 
lai'ge  to  be  taken  out  by  the  vagina. 

To  this  we  may  add  that  in  a  case  of  myoma  complicating 
pregnancy,  when  surgical  interference  is  called  for,  myomectomy  is 
the  operation  of  election. 

Indications. 

The  decision  as  to  the  suitability  of  the  tumour  for  myomectomy 
will  depend  on  the  care  with  which  the  following  points  are  de- 
termined beforehand  :  (1)  The  presence  of  a  well-defined  pedicle. 
(2)  The  definition  of  well-defined  tumours  of  various  sizes  in  the 
uterine  wall.  (3)  The  recognition  of  an  intra-mural  fibroid  in  the 
anterior  or  posterior  wall  of  the  uterus,  while  the  uterus  itself  is 
not  much  enlarged,  as  determined  by  the  uterine  sound.  (4)  The 
determination  of  the  absence  of  serious  pelvic  complications  (Kelly). 

Ligation  of  the  uterine  arteries  may  be  called  for,  and  clamps 
and  the  temporary  rope  or  elastic  ligature  should  be  at  hand. 
Some  surgeons  prefer  to  operate  in  sterilized  gloves,  especially  in 
the  case  of  large  interstitial  myomata. 

It  is  thus  possible  to  remove  a  number  of  myomata.  Ohromi- 
cized  cumol  ligatures  are  employed  for  closing  the  cavities.  Kelly 
does  not  use  a  drainage  tube,  and  he  lays  particular  stress  on  the 
necessity  for  arrest  of  the  haemorrhage  by  interrupted  or  mattress 
sutures  applied  from  the  bottom  of  the  wound  to  the  peritoneal 
surface  of  the  areas  most  afiected. 

Loiibet  of  Paris  *  is  a  warm  advocate  for  enucleation  of  myomata,  arguing 
that  the  mortality  appears  as  low   as  -2  "94  per  cent.     He   secures  vaginal 

*  Bevue  de  Gyn.,  1902,  t.  vi.,  No.  2. 


UTERINE  SEoPLASMS—MYOMA—SUU(iICAJ.'IJ!EATi\IENT.     109 


drainage  by  dilatation  with  laminaria  tents  the  day  before  the  operation,  and 
an  incision  in  the  median  line.  He  resorts  to  abdominal  drainage  for  forty- 
eight  hours  after  the  enucleation,  whereas  the  vaginal  drain  is  kept  up  foi' 
live  days.     Multiple  myoma,  he  considers,  coutra-indicatc  enucleation. 

Morcellation. — The  patient   having    been   placed  in    a    suitable 
position,  the  same  steps  are  taken  as  in  the  operation  for  enucleation. 


Fig.  oOG. — Forceps  for  grasping  the  Tumour  in  Morcellation. 


Fig.  308. — Peax's  Cyst  Forceps,  used  ix  Morcellation. 

The  uterine  neck  is  seized  with  a  strong  vulsellum  forceps,  and 
drawn  down.  A  circular  incision  is  carried  round  the  vaginal 
attachment,  and  the  bleeding  points  are  secured  by  pres.su re  forceps. 


470 


DISEASES   OF   WOMEN. 


The  uterine  neck  is  then  freed,  the  peritoneum,  bladder,  and  ureters 
being   carefully  avoided.     When  the  tumour  to  be  removed  is  of 


Fig.  309. — Doyen's  Tube  Trakchant. 

considerable  size,  the  next  step  should  be  the  ligation  of  the  uterine 
arteries.     The  cervix  is  next  divided  by   scissors  into  two  halves 


Fig.  310. — Forceps  used  with  the  Tube  Tranchant. 

by  incisions  reaching  to  the  fibroid  tumour,  and  each  half  is  held 

aside  by  a  strong-toothed  fixing 
forceps,  or  a  V-shaped  flap  is 
made  and  the  tumour  is  thus 
exposed.  It  is  then  as  far  as 
possible  examined  by  the  finger, 
the  uterus  being  drawn  well 
down  for  the  purpose.  The 
vaginal  walls  are  held  widely 
apart  by  retractors,  and  smaller 
ones  are  introduced  inside  the 
uterus,  and  with  such  forceps 
as  those  shown  (Figs.  306-308), 
the  tumour  is  grasped,  and  a 
deep  longitudinal  incision  is 
made  into  it.  Then  portion 
after  portion  is  seized  with 
somewhat  similar  forceps,  and 
a  curved  scissors  being  carried 
under  it,  the  piece  thus  caught 
by  it  is  excised.     Two  or  more 

forceps  are  used,  and   a  second  portion  of   the  growth  is  caught 


Fig.  311. — Morcellatiox  of  Anterior 
"Wall  of  Uterus  ix  Strips.   (Landau.) 


UTERINE   NEOPLASMS— MYOM A — ^UnGICM.    THEATMENT.     171 


before  that  first  seized  is  removed.    The  bistoury  has  a  short,  broad, 
and  strong  blade. 

Some  tumouis  bleed  more  readily  than  others,  rendering  the 
successive  removal  of  each  portion  moie  difficult  than  in  the  case  of 
bloodless  fibroids. 

Should  other  small  myomata  be  found  in  the  neighbourhood  of 
the  larger  mass,  these  and  other  fibromatous  nuclei  should  be  re- 
moved by  enucleation  or  morcellation.  Haemostatic  forceps  are 
freely  availed  of  in  cases  where  there  is  much  bleeding.  The  operator 
has  a  large  number  of  gauze  tampons  on  holders  ready  to  hand,  to 
staunch  the  blood  and  enable  him  to  see  the  bleeding  points.  All 
clots  are  removed.  Forcipressure  and  sponging  are  assisted  by 
hot  irrigation.  In  some  cases,  where  the  mass  removed  is  very 
large  and  the  bleeding  difficult  to  restrain,  forceps  are  allowed  to 
remain  on  from  thirty-six  to  forty -eight  hours  after  the  operation, 
tampons  of  iodoform 
gauze  being  packed  in 
between.  Otherwise  it 
is  sufficient  to  suture 
the  wounds  in  the 
uterine  neck. 

Morcellation  of  a 
large  fibroma  may  also 
be  practised  by  Doyen's 
method,  thus  :  A  large 
V-shaped  mass,  the 
base  of  the  V  reaching 
to  a  short  distance  be- 
neath the  broad  liga- 
ments, or  level  with 
these,  is  seized  in  a 
strong  claw-forceps  by 
its  apex,  and  held 
firmly  while  successive 
lozenge-shaped  masses 
are  seized  with  the 
forceps,  and  cut  away 
until  the  entire  tri- 
angular mass  is  re- 
moved. In  this  man- 
ner the  bulk  of  the  tumour  is  so  reduced  that,  when  it  is  seized 


Fig.  312. — Morcell.vtiox  for  .Submucous  FiBiioiiA 
— V-SHAPKD   Flap   PvAISED   ox  Axteriok  Wall. 

(DOYEX.) 


472 


DISEASES   OF    WOMEN. 


transversely,  it  can  be  drawn  down  to  the  vulva.  Introduction  of 
the  finger  may  be  feasible  between  the  tumour  and  the  uterine  cover- 
ing, and  it  may  be  in  this  manner  detached  from  its  cellular  bed. 

Submucous  ribromata. 

In  the  case  of  large  intra-uterine  submucous  fibromata,  and  also 
in  certain  interstitial  ones,  morcellation  is  practised  thus :  The 
uterus  is  incised  along  its  anterior  wall  with  a  V-shaped  incision, 
and  the  flap  thus  formed  is  raised  over  the  tumoui',  the  lower  part 


Fig.  313. — V-shaped  flap  kaisep,  and  the  Portion  removed  by  the  Drill 

SHOWN. 

of  which  is  thus  exposed ;  or  the  section  is  made  in  the  form  of 
a  Y,  the  stem  reaching  to  the  os  uteri,  and  the  two  branches 
extending  laterally  in  the  direction,  of  the  broad  ligaments.  The 
tuhe  tranchant  of  Doyen  (Fig.  309)  is  here  of  special  use,  as  it  drills 


UTERIM:    .\EOT'LAf<Mf!—MYOMA—Sl'J!(llC.\L     IHKA  TMKXT.     478 


a  large  tunnel  through  the  substance  of  the  tumour ;  or,  again,  the 
wall  of  the  tumour  is  incised  in  lozenge-shaped  pieces,  and  these  are 
removed  portion  by  portion  from  the  hollowed-out  space  l)ored  by  the 
sharp  drill,  the  now  friable  libroma  being  extracted  in  fragments  by 
forceps.  The  more  friable  the  tumours  are  the  more  readily  are  they 
removed.  The  nature  of  the  movcellation,  and  the  technique  of  the 
operation,  must  depend  upon  the  size  of  the  fibroma  and  its  con- 
sistence. The  primary  .step  in  these  cases  is  always  careful  separation 
of  the  bladder  and  detachment  of  the  peritoneum,  with  the  ligature, 
whenever  necessai-y,  of  the  uterine  vessels.  When  the  fibroma  has 
been  enucleated,  the  incision  on  the  anterior  wall  is  closed  with 
catgut  suture,  and  the  ca^'ity  is  tamponed  temporarily  with  sterilized 
iodoforni  gauze,  or  ordinary  sterilized  gauze  wet  with  formalin 
solution.  This  tampon  is  removed  on  the  second  day,  and  intra- 
uterine and  vaginal  douches  are  given.  The  douches  are  repeated 
frequently,  five  or  six 
times  in  the  twenty- 
four  hours,  and  the 
temperature  is  care- 
fully watched. 

Myomectomy  for  a 
Pediculated  Myoma, 
the  Uterine  Cavity  not 
being"  opened. — A  tem- 
porary elastic  ligature 
or  the  rope  of  Tait  is 
placed  as  low  as  pos- 
sible on  the  uterus. 
When  the  tumour  is 
delivered,  the  treat- 
ment of  the  pedicle 
will  depend  upon  its 
size, — when  small  by 
ligature;  but  if  of  a 
larger  size  and  thick, 
it  is  compressed  by  a 
powerful  clamp-forceps, 
and  the  tumour  is  cut 
at  a  sufficient  distance 

so  as  to  peel  off  the  peritoneum  and  fashion  the  stump,  which  is 
carefully  covered  by  it.     This  is  done  with  gut  suture.     When  all 


Fig.    314. — Application    op    the    '  Tube    Tran- 

OHANT  '    Oi:   DltlLL   OP   DoYEN   TO   THE    TOMOUIi. 


474 


DISEASES   OF   WOMEN. 


bleeding  is  stayed  by  means  of  forceps  or  ligature  of  the  separate 
points,  the  pedicle  is  returned  into  the  abdomen. 

ribromata  of  the  Broad  Ligaments — Decortication. — The  tumour 
may  protrude  by  a  comparatively  small  pedicle  into  the  peritoneal 
cavity,  or,  on  the  contrary,  its  base  of  attachment  may  be  thick, 
and  the  greater  portion  of  the  tumour  be  in  the  true  pelvis.  In 
the  former  case  it  may  be  possible  to  remove  it,  as  in  the  operation 
of  myomectomy.  Should  this  not  be  so,  the  adnexa  on  the  side 
corresponding  to  the  tumour  have  to  be  drawn  well  forward,  and 
the  broad  ligament  is  divided  between  two  T-shaped  clamp-forceps, 
the  greatest  care  being  taken  to  avoid  wounding  the  bladder,  which 
is  often  found  in  close  contiguity.  A  circular  incision  is  made 
if  the  tumour  be  large,  or  a  longitudinal  one  will  be  sufficient 
should  it  be  of  a  comparatively  small  size.  The  margins  of  the 
incision  having  been  seized  with  clamp-foi-ceps,  the  tumour  is  drawn 
forwards  by  a  strong  claw-forceps,  and  its  covering  peeled  off 
gradually  with  the  fingers,  bleeding  being  controlled  in  the  usual 
manner  during  this  step.  The  pedicle  is  secured  by  strong  com- 
pression forceps  or  the  angiotribe  of  Zweifel.     It  is  then  removed, 


Fig.  3]  5. — Doyen's  Supka-eubic  Eeteactoe. 
For  use  iu  hysterectomy. 

and,  the  bleeding  ends  of  any  vessels  having  been  secured  by  gut 
ligatures,  the  peritoneum  is  carefully  peeled  back,  the  stump  is 
fashioned  and  then  covered  with  the  peritoneal  Haps  by  sutures. 
In  all  such  cases  both  operator  and  patient  must  be  prepared  for 
hysterectomy. 


CHAPTER    XXVT. 

UTERINE    NEOPLASMS— MYOMA  (continued)— 
SURGICAL    TREATMENT. 

Abdominal  Pan-Hysterectomy. 

By  Ligature. 

Appliances  Required  for  Operation. — In  the  chapter  on  Asepsis 
and  Antisepsis  I  have  already  referred  to  all  the  preliminary  steps 
in  the  preparation  of  the  room,  the  nurses,  the  assistants,  the 
patient,  and  the  ajipliances  necessary  for  a  laparotomy  operation. 
In  abdominal  hysterectomy  it  is  well  to  have  all  the  following 
instruments  sterilized  and  ready  to  hand  : — 

A  few  scalpels  and  a  blunt-pointed  bistoury. 

A  number  of  hsemostatic  forceps — Pean's,  Wells',  Zweifel's  and 
Doyen's. 

Some  Kocher's  clamp  forceps. 

Two  of  Bilroth's  clamp  forceps. 

Variously  curved  sharp-pointed  and  blimt  scissors. 

Doyen's  helicoid. 

Tenacula,  single  and  double. 

Clamps,  various  sizes — slender,  strong,  and  curved,  and  an 
ovarian  ring  clamp. 

Four  light  clamp  forceps,  as  sponge  and  dab-holders. 

Retractors — glass  (author's)  or  other. 

Broad  ligament  needles  of  various  sizes  (Deschamps'). 

Needle-holders  (preferably  Olshausen's,  Schauta's,  and  Doyen's 
peritoneal). 

Tait's  rope  ecraseur. 

Paquelin's  or  the  electric  cautery. 

A  trocar  and  cannula. 

Steps  of  the  Operation— Preliminary  Incision — Exposure  of 
Tumour. — Up  to  a  certain  stage  the  steps  are  all  the  same  in  every 
intra-peritoneal  operation.     The  incision  varies  in  length  according 


476 


DISEASES   OF   WOMEN. 


to  the  size  of  the  tumour  to  be  removed.  It  may  have  to  be  pro- 
longed upwards  by  scissors  or  bistoury.  The  surgeon  keeps  in  the 
middle  line,  avoiding  the  rectus  sheath.  Should  he  open  it,  he 
completes  the  incision  by  cutting  directly  through  the  muscle. 
Some  surgeons  prefer  to  open  the  abdomen  through  the  rectus 
muscle,  as  the  author  does  frequently.  It  is  thought  by  some  that 
by  so  doing  the  risks  of  hernia  are  lessened.  The  cleaner  the 
abdominal  wound  the  better.  Bruising  the  tissues  and  laceration 
of  the  muscle  fibres  are  to  be  avoided. 

Haemostatic  forceps  are  applied  to  the  bleeding  points,  and  all 
haemorrhage  quickly  arrested  by  forci-pressure,  or,  should  this  fail. 


Fig.  316. — Wells'  Hemostatic  and  Torsion  Forceps. 


Fig.  317. — SLE^^)ER  Clamp,  wmcH  can  be  used  also  as  Sponge  and 
Gauze-dab  Holder. 

(s  size.) 

by  fine  gut  ligature.     It  is   not  wise    to  make   the  first  incision 
longer  than  five  inches,  or  to  approach  too  closely  to  the  symphisis. 

Extreme  Obesity. — A  fat  abdomiaal  -wall  requires  a  correspondingly  long 
incision,  otherwise  it  will  be  found  very  difficult  to  see  the  parts,  to  deliver  a 
tumour,  or  to  manipulate  within  the  abdomen. 

Superficial  Adhesions. — After  the  preliminary  incision,  and  when  the  tumour 
is  exposed,  should  adhesions  be  detected  by  the  fingers  or  hand,  the  incision 
must  be  extended  with  strong  angular  scissors  or  scalpel,  care  being  taken  in 
cutting  towards  the  bladder,  which  in  some  tumours  or  cysts  lies  rather  high. 
The  peritoneal  opening  should  ahvays  be  of  the  same  size  as  the  external 
wound. 

The  peritoneum  is  opened  by  holding  it  well  up  with  two  catch 
forceps,  and  dividing  it  with  a  scalpel  horizontally  between  the  two. 


I'TEUIXE   XEOPLASM^—MTOMA — "^rBGICAL    TREATMEXT.     477 


It  is  next  incised  to  the  necessary  extent  with  a  straight  blunt- 
pointed  bistoury. 

Tlie  position  of  the  fundus  of  the  bladder  is  determined  by  the 
introduction  of  a  sound.  Catch  forceps  are  then  applied  to  the 
peritoneal  margin  on  either  side,  both  being  thus  readily  held  apart. 

The  tumour  is  next  examined  by  the  hand  introduced  into  the 
wound,  and  its  extent  and  surroundings  are  carefully  determined. 
Its  depth  in  the  pelvic  cavity,  the  form  of  its  pedicle,  and  the 
extent  of  the  adhesions  (if  any)  are  ascertained. 


Fig.  318. — Peritoneal  Knife  of  Cook  (Virginia),  with  Flat  Blade 
ENniNG  IN  Sharp  Blunt-pointed  Beak. 

Useful  ill  cases  of  peritoneal  adhesions  to  the  bowel  and  other  viscera. 

Here,  if  it  be  thought  necessary,  the  length  of  the  abdominal 
opening  is  increased  ;  this  may  be  done  either  with  the  scalpel  or 
with  strong  blunt-pointed  scissors  (Fig.  347).  It  may  have  to  be 
prolonged  by  the  side  of  the  umbilicus  as  far  as  the  xiphoid 
appendix.  Care  must  be  taken,  in  cases  where  there  have  been 
previous  attacks  of  general  peritonitis,  lest  the  bowel  be  so  adherent 
to  the  peritoneum  that  it  runs  the  risk  of  being  opened  when  the 
latter  is  incised. 

The  Transverse  Kuestner-Rapin  Incision. 

Pfannenstiel  *  and  Mange  f  have  recently  written  advocating  in  certain 
cases  the  Kuestner-Eapin  incision,  which  is  carried  through  the  aponeurosis 
of  the  abdominal  muscles  whenever  possible  inside  the  limit  of  the  pubic 
hair.  This  latter  incision  Menge  prefers  when  the  operative  procedure  is 
mainly  in  the  pelvis.  Pfannenstiel  prefers  the  usual  higher  transverse  one. 
The  incision  through  the  recti  is  made  vertically.  The  aponeurosis  and  the 
subcutaneous  fat  are  separately  stitched.  At  the  same  time,  in  the  case  of 
the  larger  tumours,  the  vertical  incision  is  still  adopted  by  both  operators. 
Menge,  however,  resorts  to  the  transverse  one  even  in  some  of  these  latter. 
The  principal  advantages  of  the  transverse  incision  are  said  to  be  the  better 
cosmetric  effect,  and  the  avoidance  of  hernia. 

The  next  step  is  the  separation  of  the  parietal  adhesions,  if  they 
be  present ;  this  may  be  done  with  the  finger. 

Small  bleeding  points  are  treated  by  pressure,  and  any  bleeding 
vessel  of  a  separated  adhesion  is  secured  by  a  iine  gut  ligature. 
*  Samml.  U.  Vortmegc,  n/.,Xo.  26S.     f  Monah.f.  Geh.  und  Gyn.,  bd.  17,  s.  12.">f). 


4:78 


DISEASES   OF   WOMEN. 


Should  the  day  be  dark  and  the  light  defective,  the  lamp  (Fig.  85) 
will  suffice.  Its  reflector  can  be  turned  at  any  angle  and  retains 
its  position.  Or  the  forehead  reflector  can  be  availed  of.  The 
bowel  is  now  carefully  protected  by  means  of  small  moist  sterilized 
protectors  wrung  out  of  weak  formalin  solution,  and  nipped  at  one 
corner  with  a  pi-essure  forceps. 


Fig.  319. — Forehead  Eeflectok. 

Retractors  are  useful  for  drawing  the  abdominal  wall  at  either 
side  of  the  incision  apart,  and  the  glass  ones  of  the  author  are  con- 
venient for  this  purpose  (Fig.  320).     The  extreme  Trendelenburg 

position  may  be  ne- 
cessary in  some  cases 
to  expose  the  pelvis 
thoroughly,  in  the 
management  of  ad- 
hesions and  the  con- 
trol of  bleeding 
points. 

The  delivery  of  the 
myoma  is  frequently 
difficult,  and  has  to 
be  conducted  with  the 
greatest  care.  Adhesions  may  be  torn  through  by  roughness,  and 
the  viscera  thus  injured.  It  is  also  of  importance  to  avoid  bruis- 
ing the  parietes,  thus  injuring  their  vitality.  The  delivery  of  the 
tumour  may  be  assisted  by  its  elevation  by  means  of  pressure 
made  through  the  vagina  by  an  assistant.     The  corkscrew  of  Tait, 


Fig.  320.— Glass  Eeteagtoks  of  Author 
(self-retaining  if  required). 


VTEIUXE  SF.nri.A>^M.^—M  YOM A— SURGICAL    TI!EATME.\T.     479 


the   helicoid    of   Doyen  (Fig.    340),  or   the  elevator  of   Reverdin, 
are  of  use  in  the  delivery  of  large  myoniata.     If  we  find  that  we 


Fig.  321. — Segond's  Bivalve  SELF-RETAiNnxG  ABDoinxAL  Ketkactor. 
The  blades  are  movable. 


Fig.  322. — Delivery  of  a  Fibromtoma  with  the  Helicoid  op  Doyen. 

(DOYEX.) 

From  a  photograph. 


480  DISEASES   OF   WOMEN. 

cannot  deliver  the  myoma  in  consequence  of  its  depth  in  the 
pelvis,  or  the  associated  myomatous  growths  between  the  layers  of 
the  broad  ligament,  we  must  proceed  to  divide  and  ligature  the 
latter ;  or  temporary  compression  of  the  ligament  between  clamps 
is  made,  allowing  of  its  section  at  either  side,  so  as  to  permit  of  the 
delivery  of  the  tumour. 

The  Presence  of  Pus.— The  presence  of  free  pus  in  the  pelvic  cavity,  if 
detected  wJien  the  patient  is  in  the  Trendelenburg  position,  will  necessitate 
immediate  lowering  of  the  table,  and  careful  exclusion  of  the  exposed  surface 
of  the  bowel  with  gauze  and  flat  sponges.  In  these  cases  especial  care  must 
be  taken  when  the  pelvis  and  abdomen  are  freed  of  the  tumour  to  cleanse  the 
cavity  with  formalin  dabs,  or  to  flush  it  out  with  sterilized  saline  solution.  I 
prefer  the  formalin  method. 

Bowel,  Eectal,  and  Bladder  Adhesions. — In  detaching  these,  great  care  must 
be  exercised.  The  best  plan  is  to  work  towards  the  uten;s,  and  away  from 
either  viscus,  with  the  finger  nail,  and  with  a  small  sponge  or  roll  of  gauze 
we  complete  the  detachment  as  far  as  we  prudently  can.  We  again  resort  to 
the  finger  nail  or  blunt-pointed  curved  scissors,  and  repeat  the  peeling  process 
with  the  sponge.  Should  it  be  either  impossible  or  rash  to  proceed  with  the 
separation  of  bowel  or  vesical  adhesions,  it  is  better  to  separate  with  the 
scissors  a  thin  layer  of  the  tumour  tissue,  which  may  be  left  attached. 

Position  of  the  Adnexa. 

It  is  important  to  bear  in  mind  the  relative  position  of  the  adnexa  to  certain 
tumours.  Doyen  has  shown  these  several  relations  of  the  adnexa  to  various 
tumours  in  a  series  of  schemes  drawn  from  the  conditions  he  found  in  his 
operations.  In  some  the  difficulty  of  securing  permanent  haemostasis  was 
necessarily  great.  This  relation  is  dependent  upon  the  mode  of  growth  and 
the  original  point  of  development  of  the  tumour.     It  will  also  be  influenced 


Kocher's  Clamp  Forceps. 
(6  sizes.) 

by  the  shape  and  multiple  nature  of  the  fibroma.  If,  for  example,  the  tumour 
shoidd  distend  and  fill  the  uterus,  being  of  the  submucous  character,  it  will 
push  the  adnexa  upwards  towards  the  upper  zone  of  the  tumour.  A  sessile 
subperitoneal  tumour,  springing  from  the  fundus  of  the  tumour,  will  have  the 
adnexa  directly  beneath  its  liase,  whereas,  if  it  be  pediculated,  they  will  be 
found  in  their  usual  position ;  a  large  multiple  fibroid  springing  from  the  fundus, 


UTKlilXE   NEOPLASMS— MYUM A— sr Ua WA L    IRKATMENT.     481 


and  depressing  the  uterine  cavity,  has  them  lying  underneath  its  base  and 
attached  to  it.  A  tumour  developed  in  tlie  posterior  wall,  and  encroaching 
on  the  space  of  Douglas,  will  push  the  ovaries  and  tubes  aside ;  the  adnexa 
may  thus  be  found  either  on  the  summit,  or  spread  out  on  the  side  of  the 
tumour.  So  if  it  be  developed  in  the  lateral  wall  or  in  the  broad  liga- 
ment, the  pelvic  peritoneum  and  ovary  will  cover  it.  Associated  perimetric 
conditions,  surli  as  salpingo-ovaritis,  will  cause  adhesion  and  attachiuont  of 
the  adnexa. 

When  the  tumour  lias  been  withdraw ii  from  the  abditminal  cavity 
it  is  supported  by  an  assistant,  and  its  pedicle  is  temporarily  secured 
by  a  sti-ong  clamp  forceps.     The  intestines  are  protected,  and  all 


Ftg.  324. — LiGATuiiF.  Hook.    (Sanitee.) 

The  hook  is  turned  at  such  an  angle  as  to  require  only  half  a  rutatioii  of  the 
liandle  to  vigorously  catch  the  loop  of  the  ligature. 

bleeding  points  are  secured.  This  protection  of  the  peritoneum 
and  intestine  after  the  delivery  of  the  tumour  is  a  matter  of  the 
greatest  moment  in  a  prolonged  operation.       Both  extrusion  and 


Fig.  825.— Curved  Needled.         Fig,  326. — Doyex's  Peritoneal  Neehle- 
Patterns    used    by    author.       The        holder,  with  the   Eye   between  the 
steel  of  these  needles   must   be        Blades  for  thk  Needle. 
carefully  tempered  so  that  they 
\vill     stand     both     considerable 
strain  in  use  and  also  the  pres- 
sure of  the  clamp  ueedle-holder. 

exposure  of  the  bowel  have  to  be  vigorously  guarded  against.     The 
intestines  should  be  covered   with  w^arm   protectors,   wrung  out  of 

2  I 


482 


DISEASES    OF   WOMEN. 


sterilized  water  containing  formalin.  Maunsell  devised  a  useful  guard 
for  this  purpose,  a  frame  of  copper  wire  covered  with  rubber-tubing, 
over  which  layers  of  aseptic  gauze  are  stretched.  A  sound  should 
now  be  passed  into  the  bladder.  If  there  be  danger  of  the  viscus 
being  wounded,  and  if  it  be  expanded  over  the  face  of  the  tumour, 
the  sound  is  a  guide  to  its  position.  The  bladder  must  then  be 
separated  from  the  tumour  by  the  thumb  or  piece  of  dab  or  sponge 
on  a  holder,  pushing  towards  the  uterus.  Cases  have  been  pub- 
lished in  which  the  bladder  reached  to  the  umbilicus.  It  did  so  in 
a  case  of  the  author's  where  the  operation  was  performed  for  double 
pyo-salpinx. 

If  the  bladder  wall  be  wounded,  it  must  be  immediately  closed 
by  gut  or  fine  silk  sutures,  as  in  the  instances  of  the  intestines.  It 
may  be  found  that  it  is  impossible  to  deliver  the  tumour,  owing  to 


Figs.  327,  328.— Olshausen's  Begad  Ligament  Needles 
(Straight  and  Double  Oukved). 

There  are  two  sizes  of  each. 

its  depth,  the  extent  of  the  adhesions,  and  the  shortness  of  the 
pedicle.  It  has  then  to  be  dealt  with  by  one  of  the  other  methods 
we  shall  refer  to.  In  clearing  it  in  front,  the  ureters  may  be 
wounded.  The  degree  of  laceration  and  displacement  must  influence 
the  course  to  be  pursued.  The  methods  of  dealing  with  a  divided 
ureter  are  considered  in  the  chapter  on  the  Surgery  of  the  Ureters. 
Ligature  and  Division  of  the  Broad  Ligaments. — Before  pro- 
ceeding to  apply  the  ligatures,  the  surgeon  carefully  examines  the 
adnexa  and  broad  ligaments  at  either  side,  ascertaining  if  there  be 
any  tumours  or  cysts  of  the  adnexa,  and  the  relations  of  the  latter 
to  the  tumour.  He  should  get  a  good  idea  of  the  position  of  the 
cervix,  and  the  line  of  utero-vesical-peritoneal  reflexion.  Any 
deviation  from  the  usual  position  or  course  of  the  ureters  is  sought 


UTEklNE  XEOrLASMS—Ml'uMA—SUliiJLCAL    TREATMENT.     iS3 


for,  and  it  may  be  possible  to  palpate  them  in  their  passage  to  the 
bladder.  He  next  proceeds  to  ligature  the  broad  ligament  at  one 
side,  using  the  curved  needle  of  Olshausen  for  this  purpose.     If  we 


Fig.  829. — Olshausex's  Sharp  Curved  Xeedle,  with  Eye  ix  Poixt. 
(Several  curves.) 

intend  to  remove  the  tube  and  ovary,  a  ligature  is  passed  outside 
these  and  firmly  tied,  another  is  carried  close  to  the  uterine  wall, 
and  the  Inroad  ligament  is  divided.  The  same  manceuvre  is  carried 
out  at  the  other  side.  The  ovarian  arteries  have  now  been  both 
secured.  Any  bleeding  vessels  on  the  uterine  side  can  be  tem- 
porarily caught  with  pressure  forceps. 

If  the  adnexa  be  healthy,  they  may  be  left,  or  those  of  one  side 
only  removed.  The  middle  portion  of  the  broad  ligament  to  the 
level  of  the  internal  os  is  next  ligatured  at  either  side. 

The  sound  iu  the  bladder  indicates  the  line  of  peritoneal  reflexion 
and  attachment.     A  curved  incision  is  carried  from  one  broad  liga- 


FiG.  330. — DoYEx's  Long  Foeoeps  pou  seizisg  the 
Utekixe  Arteet  axt)  drawing  it  out  foe 
Ligature. 


ment  to  the  other,  across  the  anterior  surface  of  the  uterus,  and 
through  the  sub-serous  connective  tissue.  "With  the  thumb  or  a 
small  sponge  on  a  holder,  which  is  much  better,  the  detachment 
of  the  bladder  is  effected  as  far  as  the  vagina.  An  obturator, 
passed  into  the  vagina  and  pushed  upwards,  will  indicate  the  point 
where  the  vagina  may  be  opened,  which  is  done  by  cutting  on  the 


484 


DISEASES   OF   WOMEN. 


obturator  or  a  long  curved  forceps,  the  blades  of  which  can  be 
separated  to  stretch  the  anterior  vaginal  A^ault  and  enlarge  the 
opening,  with  a  curved  scissors,  or  the  finger  may  be  used  for  the 
same  purpose.  The  posterior  fornix  is  now  put  on  the  stretch  by 
hooking  the  finger  through  the  opening  just  made  and  drawing  on 
the  cervix,  while  at  the  same  time  it  is  used  as  a  guide,  or  the 
cervix  may  be  seized  by  Doyen's  erigne  (Fig.  342),  and  drawn  back- 
wards and  forwards  or  to  either  side.  The  vault  is  now  opened 
posteriorly.  This  opening  is  likewise  enlarged  with  the  finger. 
The  next  step  consists  in  the  ligaturing  of  the  uterine  arteries  and 
the  severing  of  the  uterus.  This  involves  the  avoidance  of  two  most 
serious  accidents — ha3morrhage  and  a  wound  of  the  ureter.  The 
liability  to  one  or  other  will  depend  upon  the  care  and  deliberation 
with  which  the  step  is  conducted,  and  the  probability  of  either 
accident  occurring  will  be  largely  influenced  by  the  character  of  the 


Bilroth's  Clamp. 

It  closes  square  at  the  end — has  serrated  blades,  which 
meet  perfectly.  It  is  a  most  valuable  clarop.  light 
and  handy,  for  seizing  pedicles,  etc. 

tumour,  its  shape,  depth  in  the  pelvis,  the  height  to  which  the 
ureters  are  carried  by  the  mass,  and  the  disposition  of  the  uterine 
vessels,  Sometimes  the  uterine  artery  or  a  branch  is  wounded 
unexpectedly  through  an  abnormal  division.  Should  this  occur, 
the  trunk  is  immediately  seized  with  a  Doyen's  forceps,  drawn  well 
out,  and  tied.  The  curved  needle,  is  passed  as  close  as  possible  to 
the  uterine  neck,  so  as  to  avoid  the  ureter.  The  curved  scissors, 
with  the  convexity  turned  towards  the  uterus,  cuts  close  into  the 
uterine  tissue.  This  is  done  at  both  sides  of  the  cervix,  and  finally 
the  uterus  with  its  tumour  is  completely  delivered. 

Any  bleeding  points  are  now  sought  for,  and  each  in  turn  is 
secured  with  a  ligature.  The  source  of  any  oozing  is  patiently 
looked  for  and  controlled,  whether  in  the  pelvis  or  from  the  cut 
vaginal  surface.  This  must  be  done,  with  the  patient  thrown  well 
into  the  Trendelenburg  position,  and,  if  necessary,  by  the  light  of 


I'TERISE   XEOPLASMS—^fyo.VASUBH/CAL    TJ.'LA  TMKST.     185 


the  forehead  mirror  (Fig.  310),  The  pelvis  is  now  thoroughly  dried 
out  with  damp  compresses  of  sterilized  gauze,  ami,  when  all  is 
perfectly  clean  and  dry.  a  roll  of  iodoform  gauze  is  carried  from 


Fig.  3?>2. — Short  Forci-pressure 
forcep.s  of  doyex. 


above  down  into  the  vagina,  a  small  portion  only  of  it  being  left 
pi-ojecting  into  the  peritoneal  cavity.  The  peritoneal  flaps  are  now- 
sewn  with  continuous  or  interrupted  sutures,  and  any  rents  in  the 
broad  ligament  are  carefully  closed.     The  pedicles  of  the  adnexa. 


Fig  333.— Zweifel's  Small  Crushing  Forceps.    Fig.  33i.— Forceps  Closed. 


These  forceps  are  most  valuable.  They  are  about  the  size  of  an  ordinary  Well's 
forceps.  The  crushing  power  at  the  points  is  increased  threefold  by  the 
mechanism  of  the  forceps.  They  completely  control  the  bleeding  from  any 
small  vessels  if  allowed  to  remain  on  for  a  short  time. 

if  the  latter  are  removed,  are  carefully  tucked  in  and  covered  with 
peritoneum.  Finally  the  vaginal  opening  with  the  peritoneum  is, 
sutured  over  the  gauze. 


486 


DISEASES   OF    WOMEN. 


Fig.  335. — Passage  of  the  Double  Ligature  at  Upper  Third  of  Broad 
Ligament.    (C.  Martin.) 


4S^ 


Fig.  386.— Successive  Ligatures  op  Broad  Ligament.    (C.  Martin.) 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     487 


^^'^m&u- 


FiG.  337. — Ligature  cut  shorthand  Pedicle  dropped.    (C.  Martin.) 


Fig.  338. — Eoll  op  Iodoform  Gauze  dra^wi^  down  through  the  Vagiva, 

LEATIXG   AN    InCH   ABOVE   IT.      (C.    MaRTIN.) 

Looking  down  from  above  on  the  pehic  basin,  in  the  completed 
operation  no  jagged  or  exposed  surfaces  are  seen,  the  peritoneal 
edges  are  carefully  approximated,  leaving  one  continuous  smooth 
and  clean  surface. 


488  DISEASES   OF   WOMEN. 


In  the  hands  of  the  most  distinguished  operators,  adhesions  between  the 
intestine  and  omentum  and  the  abdominal  wall,  after  operation  by  the 
abdominal  route,  and  between  the  intestine  and  omentum  and  the  edges 
of  the  vaginal  wound,  in  vaginal  hysterectomy,  as  well  as  prolapse  of  the 
vagina,  occur  when  the  peritoneum  is  not  carefully  united  in  either  case. 

Should  the  case  have  been  complicated  with  severe  hsemorrhage, 
and  we  fear  further  oozing,  or  if  there  have  been  such  complications 
as  cystic  and  dermoid  tumours,  or  hsemato-  or  pyo-salpinx,  and  the 
contents  of  the  cysts  or  sacs  have  escaped  during  the  operation,  it 
is  better  to  leave  the  vaginal  opening  unclosed,  and  to  let  the 
iodoform  roll  act  as  an  efficient  drain.  Within  a  few  days  the  peri- 
toneal cavity  is  shut  off  by  a  layer  of  encapsuled  lymph,  and  thus 
infection  from  below  is  prevented. 

The  abdominal  toilet  is  now  completed,  the  peritoneal  edges  are 
brought  together,  and  are  united  by  a  continuous   or  interrupted 


Fig.  339. — KEVERraN's  Needle. 

The  needle  having  been  passed  through  the  lips  of  the  wound,  the  silk  or  gut 
is  caught  in  the  notch,  and  it  is  drawn  back.  This  is  the  best  needle  for 
use  if  interrupted  sutures  of  silkworm  gut  be  selected  to  close  the  skin. 
The  needle  is  carried  rapidly  from  one  margin  of  the  wound  to  the  other, 
the  thread  is  linked  into  the  slit  by  an  assistant,  and  the  needle  quickly 
withdrawn.  The  ends  are  caught  in  catch  forceps,  and  the  tying  is  rapidly 
completed  when  all  the  sutures  are  passed.  This  needle  may  be  had  of 
different  curves,  or  with  an  eye  in  the  point. 

suture  of  fine  gut.  The  rectal  fascia  is  next  raised  off  the  muscle 
for  an  inch  in  width  at  either  side  with  the  fingei'-nail,  the  end  of 
closed  scissors,  or  the  scalpel.  The  muscle  and  fascia  are  sutured 
with  gut  of  medium  consistence,  special  care  being  taken  to  bring 
the  edges  of  the  fascia  into  accurate  line.  (Noble  makes  its  margins 
overlap,  and  thus  stitches  it.)  Finally,  the  skin  margins  are  united 
with  silkworm  gut,  bronze  aluminium  wire  or  celloidinzwirn.  I 
invariably  use  the  latter. 

Drainage  is  rarely  required — never  when  there  has  been  an 
aseptic  operation,  and  if  all  bleeding  have  been  thoroughly  arrested. 
If  however,  there  have  been  any  suppurative  conditions  of  the 
adnexa,  and  pus  has  escaped  into  the  peritoneum,  or  blood  into 
the  pelvic  cavity,  and  there  is  a  certainty  of  serous  oozing  following 


UTEMIXE  NEOPLASMS— MYOMA— SUROICAL    TREATMENT     489 

the  operatic Q,  it  is  well  to  drain.*  This  may  be  done  either  with  a 
rubber  tube,  which  has  been  sterilized,  or  by  a  sterilized  iodoform 
gauze  drain.     The  drain  should  be  removed  as  soon  as  possible. 


Doyen's  Operation  of  Abdominal  Pan-Hysterectomy  (with  Clamps). 

The  first  stage  of  the  operation  is  similar  to  that  which  has  been  described. 
The  tumour  is  then  drawn  forward  by  his  helecoide  (corkscrew  tractor).  If 
tliere  be  a  pedicle,  and  the  tumour  can  be  drawn  over  the  pubes,  this  is  imme- 
diately done.  His  supra-pubic  self-retaining  retractor  is  now  applied.  The 
bowel  is  carefully  protected,  and  the  extirpation  of  the  tumour  proceeded 
with.  The  second  stage  consists  in  the  extirpation  of  the  utenis  and  the 
lisemostasis  of  its  pelvic  attachments.  This  part  of  the  operation  is  performed 
very  quickly,  and  without  the  use  of  preventive  clamps.  A  long  curved 
forceps  is  inti'oduced  into  the  sterilized  vagina,  and  is  pushed  behind  the  neck 
of  the  uterus  so  as  to  protrude  the  posterior  vaginal  cul-de-sac  upwards  as  far 
as  possible.     By  this  means  the  exact  height  of  the  reflection  of  the  anterior 


Fig.  340. — HELECoroE,  for  Delivery  of  TuiiorR.     (Doyex.) 

wall  of  the  cul-de-sac  of  Douglas  is  defined,  and  a  thick  thread  of  silk  is 
immediately  passed  about  a  centimetre  above  this  point.  This  suture  sei'ves, 
at  the  end  of  the  operation,  to  draw  up  the  posterior  lip  of  the  peritoneal 
wound  and  facilitate  the  closure  of  the  vaginal  orifice.  A  longitudinal 
incision,  suflSciently  free,  is  next  made  into  the  cul-de-sac  of  Douglas  on  the 
point  of  the  forceps,  either  by  bistoury  or  scissors.  The  surgeon  now  inti'o- 
duces  the  right  index  finger  through  the  vagmal  opening  thus  enlarged,  and 
carries  through  it  Doyen's  erigne  for  seizing  the  cervix.  This  is  plunged  into 
the  anterior  lip,  or,  if  this  be  impossible,  the  posterior,  and  by  it  the  neck  is 
securely  seized.  This  is  then  drawn  up  between  the  lips  of  the  vaginal  open- 
ing. With  the  left  index  finger,  the  lateral  attachments  are  examined,  and 
with  a  scissoi's  or  bistouiy  these  attachments  of  the  cervix,  as  far  as  the 
inferior  border  of  the  lateral  ligaments,  are  divided.  Strong  traction  is  made 
with  the  erigne  forceps.     The  anterior  vaginal  cul-de-sac  is  now  seen,  and 

*  See  p.  l.S.T  for  the  various  indications  for  resort  to  drainage. 


490 


DISEASES   OF    WOMEN. 


Fig.  341. — The  Eight  Broad  Ligament  is  detached  from  the  Uterus — The 
Tumour  is  tilted  to  the  Left — Adnexa  held  ix  the  Hand  of  the 
Assistant.     (Doten.) 


Fig.  342. — Eeigne  of  Doten  converted  to  grasp  ant)  hold  firmly  the 
Cervical  Lip  or  Neck  in  deaaving  it  up  between  the  Lips  of  the 
Vaginal  Opening. 

the  anterior  lip  of  the  cervix  is  seized  Avitli  an  ordinary  claAV  forceps,  if  this 
be  necessary,  and  the  ciil-de-sac  is  divided  \di\\  the  scissors  at  its  contact 
with  the  cerAax,  still  drawing  forciblj^  with  the  forceps  or  erigne.  With  the 
right  index  finger  the  cervix  is  carefully  separated  from  the  bladder,  and 
there  is  now  no  attachment  of  the  uterus  left  save  its  lateral  vascular 
connections. 


UTERINE  NEOPLA8M)S—MrO MA— SURGICAL    TREATMENT.    491 


Fig.  343. — Opexing  of  the  Posterioe  Vaginal  Cul-de-sac.    (Doten.) 


Fig.  344:.— Incision  op  the  Anterior  Cul-de-Sac — Raising  of  the  Uterine 
Neck  after  its  Detachment  from  the  Bladder.    (Doyen.) 


492  DISEASED   OF    W03IEN. 


It  only  Temains  to  introduce  the  left  forefinger  above  the  right  broad 
ligament  in  order  to  perforate  the  utero-vesical  peritoneum,  and,  with  the 
curved  finger,  to  complete  the  detachment  of  the  right  broad  ligament.  As 
this  is  separated,  it  is  seized  between  the  finger  and  thumb  by  an  assistant, 
and  cut  between  the  adnexa  and  the  uterus.  The  tumour  is  now  rapidlj- 
depressed  towards  the  left ;  its  anterior  serous  envelope  is  divided,  if  it  offer 
any  resistance,  as  far  as  its  connections  with  the  left  broad  ligament.  Nothing 
now  retains  it  save  the  other  border  of  the  latter,  which  a  stroke  of  the 
scissors  divides,  and  the  uterus  is  free.  As  in  the  case  of  the  right,  the  left 
broad  ligament  is  seized  by  the  fingers.  In  favourable  cases,  there  is  scarcely 
any  bleeding,  save  some  small  jets  from  the  uterine  and  utero-ovarian  vessels 
occurring  at  the  moment  of  the  extraction  of  the  uterus.  This  latter  result  is 
obtained  by  the  section  being  carried  so  close  to  the  uterine  tissue  that  the 
main  trunks  of  the  vessels  are  not  divided,  but  onh-  their  smaller  internal 
branches.  A  few  ligatures  at  each  side  are  sufficient  in  the  simpler  cases  to 
secure  the  uterine  arteries  and  their  principal  branches.  The  right  adnexa 
are  now  removed  and  resected  by  transfixion  of  the  pedicle,  which  is  tied 
circularly  by  a  silk  ligature.  The  left  are  treated  in  the  same  manner,  and 
these  ligatures  are  held  by  two  haemostatic  forceps.  The  pelvic  Cavity  is 
sponged,  and  cleansed  of  any  blood  remaining.  The  suture  of  silk  which  was 
placed  posteriorly  at  the  commencement  of  the  operation  is  now  drawn  on, 
the  vaginal  mucous  membrane  is  seized  with  one  or  two  long-toothed  forceps, 
and  it  is  united  by  two  or  three  sutures  with  the  peritoneum.  The  ends  of 
the  ligatures  tying  the  tubo-ovarian  pedicles  are  now  di'awn  into  the  vagina 
with  a  long  curved  forceps.  The  pelvic  peritoneum  has  to  be  closed.  The 
cul-de-sac  of  Douglas  is  sponged  and  dried,  the  pedicles  of  the  adnexa  at 
either  side  are  covered,  and,  in  effecting  this  closure  of  the  peritoneum,  care 
has  to  be  taken  not  to  woimdthe  vessels.  Should  this  occur,  they  are  imme- 
diately tied.  Doyen  closes  the  entire  pelvic  peritoneum  by  a  pm'se-string 
suture,  taking  in  the  posterior  circumference  of  the  peritoneal  wound,  -the 
adnexal  pedicles,  and  the  vesical  peritoneum.  It  may  also  be  closed  in  the 
usual  manner  \>j  interrupted  sutures.  Any  lateral  tear  is  carefully  repaired. 
The  toUet  of  the  pouch  of  Douglas  is  then  terminated,  the  compress  is  placed 
in  the  pelvis  at  this  point,  and  the  table  is  replaced  in  the  horizontal  position. 
The  abdominal  wound  is  then  closed.  In  certain  cases,  such  as  shortness  of 
the  broad  ligaments,  thickening  of  their  upper  border,  with  which  is  associated 
hypertrophy  of  the  round  ligaments,  there  is  considerable  resistance  to  the 
raising  of  the  tumour  through  their'  attachments  to  the  fundus.  In  such 
cases  he  di^ddes  the  ligament,  and  temporarily  secures  it  with  haemostatic 
forceps. 

In  his  later  ccelio-pan-hysterecto my, 'when  the.  vagina  has  been  opened  in 
front  and  behind,  and  the  cervix  liberated  from  the  bladder,  the  broad 
ligaments  are  seized  and  held  bj^  the  angiotribe,  the  pedicles  are  crushed,  tied, 
and  divided  at  either  side,  the  uterine  arteries  are  next  tied,  and  the  angio- 
tribe is  removed.  A  purse-sti'ing  suture  is  carried  fi'om  the  retro-uterine 
peritoneum  to  that  between  the  right  adnexa  and  the  bladder,  this  throwing 
the  stump  of  the  right  adnexa  below  the- peritoneum.  The  stump  of  the  left 
adnexa  is  treated  in  a  similar  manner,  and  a  eontimaous  suture  is  carried 


UTERINE   NEOPLASMS— MYOMA— ."iURGICAL    TREATMENT.     \\V.\ 


from  left  to  right,  approximating  the  retro-uterine  peritunenni  to  that  of  the 
hhuUler. 

Prolonged  and  Obstinate  Haemorrhage.-  Should  this  occur  low 
down  ill  llic  pelvis,  the  Treiidulcuburg  position  at  an  angle  of 
45^  must  be  obtained  ;  the  bowel  is  carefully  drawn  ujj  and  pro- 
tected. Strong  artificial  light,  by  the  electric  lamp  or  forehead 
mirror,  is  thrown  into  the  pelvis  ;  the  sources  of  the  bleeding 
determined,  and  ligatured,  if  necessary,  with  Schauta's  ligature 
tightener.  If  there  be  general  oozing,  or  the  patient's  condition 
forbids  further  efforts  to  see  and  secure  \'essels,  a  sterilized  gauze 
pack  should  be  tightly  packed  over  the  bleeding  surface.  With  the 
long,  light  clamp  needle-holder  of  Olshausen,  it  is  not  difficult  to 
carry  a  fine  needle  deep  into  the  i^eh'is,  and,  b)''  dipping  it,  secure 
the  bleeding  vessel  or  vessels. 

Shock  during  Operation,  or  immediately  after. — Wlien  any  or  all 
of  the  conditions  I  have  enumerated  so  complicate  an  operation 
that  its  duration  is  considerably  prolonged,  or  there  has  been  such 
loss  of  bleeding  that  the  patient's  life  is  endangered,  shock  may 
occur,  and  demand  immediate  attention.  A  subcutaneous  injection 
of  ether  or  strychnine  should  be  given,  a  stimulating  enema  may  be 
passed  into  the  bowel,  and  a  sub-mammary  injection  of  artificial 
serum  administered.  The  anaesthetist  is  the  one  who  is  mainly 
responsible  for  the  recognition  of  the  symptoms  ushering  in  shock  : 
increased  rapidity,  with  failure,  of  the  pulse,  growing  pallor,  weak- 
ness of  the  respirations,  and  cold  perspiration  should  warn  him  of 
the  danger. 

After  a  long  operation,  when  complications  such  as  those  men- 
tioned have  to  be  overcome,  once  the  abdominal  toilet  has  been 
made,  which  should  be  done  as  rapidly  as  possible,  the  patient  must 
be  moved  from  the  operating-table  with  gentleness,  and  steps  taken 
immediately  to  secure  a  proper  temperature  and  the  application  of 
artificial  warmth  to  the  lower  extremities.  Should  the  symptoms  of 
shock  continue,  another  stimulating  enema  may  be  given  after 
placing  her  in  bed,  and  a  second  subcutaneous  injection  of  ether,  to 
be  followed  in  a  little  time  by  one  of  strychnine.'- 

Accidents. — That  accidents  during  hysterectomy  are  not  so  uncommon  as 
some  would  represent,  may  be  realized  from  the  results  in  Chrobak's  klinik 
alone  during  two  years.  The  ureters  suffered  in  fifteen  cases,  one  ureter  in 
eleven,  both  in  four,  and   the  bladder  itself  in  twenty-one.      There  were 

*  For  full  instructions  regarding  the  treatment  of  post  operative  shock,  see 
remarks  on  after  niauaaement  of  the  case. 


494  DISEASES   OF    WOMEN. 

fourteen  injuries  to  the  bowel,  seven  abdominal,  and  seven  vaginal.  Twenty- 
one  of  these  accidents  proved  fatal.* 

Jessett  records  a  case  of  adherent  transverse  colon  embedded  between  two 
large  fibroids,  the  distal  portion  of  the  intestine  being  drawn  quite  taut  over 
the  lower  tumour,  and  in  such  close  juxtaposition  to  the  left  broad  ligament, 
behind  which  it  lay,  that  it  was  enclosed  in  the  tubo-ovarian  ligature  and 
divided.  The  accident  was  not  discovered  until  the  tumour  was  examined 
after  removal.  An  artificial  anus  was  made  at  the  proximal  end,  and  the 
distal  portion  invaginated.     Death  occurred  on  the  fifth  day. 

Splenic  Flexure  of  Colon  buried  in  Adhesions — Colon  Adherent  to  Parietal 
Peritonenm — Stomach  dilated,  thickened,  and  the  Cardiac  End  held  by  Ad- 
hesions to  the  Colon. — I  recently  removed  a  myoma  in  a  case  in  which  there 
had  been  abdominal  pain  on  and  off",  with  chronic  invalidism  for  twenty  years. 
There  had  been  long  spells  of  vomiting,  for  which  morphia  had  been  freely 
used.  Pain  was  principally  felt  at  the  left  side.  The  patient  had  a  mobile 
right  kidney.  A  year  previously  I  had  refused  to  operate,  believing  that  her 
symptoms  did  not  altogether  arise  from  the  tumour,  but  as  these  had  increased 
during  the  year  her  physician  and  friends  desired  to  have  the  operation.  The 
tumour  extended  into  the  broad  ligaments  at  either  side.  During  operation 
she  vomited  some  blood,  and  after  it  was  over  persistent  vomiting  continued 
in  spite  of  all  that  could  be  done,  until  she  died  on  the  fourth  day.  I  was 
permitted  a  partial  autopsy,  at  which  I  found  the  descending  colon  adherent 
to  the  parietal  peritoneum  by  dense  adhesive  bands  to  the  extent  of  three 
inches.  The  splenic  flexure  was  buried  in  a  tunnel  of  adhesions  for  the  extent 
of  some  four  inches.  The  stomach  was  much  dilated,  and  its  coats  thickened. 
The  cardiac  end  of  the  stomach  was  held  by  adhesions  to  the  colon.  Before 
death  I  had  opened  the  abdomen,  suspecting  that  there  might  be  some  in- 
testinal complication,  but  discovered  none.  There  was  no  tympanites  until 
shortly  before  she  died. 

Bumm's  Operation.f— A  practically  bloodless  pan-hysterectomy  is 
that  of  Bumm,  who  does  not  favour  the  supra-vaginal  method.  It 
is  specially  suitable  in  the  case  of  myomata  which  do  not  extend 
far  into  the  broad  ligaments,  and  in  malignant  disease  limited  to 
the  uterine  cavity  and  cervix,  or  cases  of  deciduoma  malignum 
and  certain  cases  in  which  the  uterus  may  have  to  be  removed 
from  hsemorrhagic  and  other  forms  of  endometritis.  The  steps  of 
the  operation  are  as  follows  : — 

The  vagina  having  been  rendered  thoroughly  aseptic,  it  is  incised 
posteriorly  and  the  pouch  of  Douglas  opened.  Any  bleeding  vessels 
are.  ligatured.  Otherwise,  a  sound  is  passed  into  the  jDOsterior 
fornix,  and  maintained  there  by  a  gauze  tampon.  The  abdomen  is 
now  opened,  the  tube  and  ovary,  preferably  of  the  left  side,  are 

*  Blau  Bettraege  z.  Geh.  u.  Gyn.,  bd.  18,  Jieft  i. 

t  For  Bumm's  radical  operation  for  cancer  of  the  uteras,  see  chapter  un 
Cancer. 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     195 


drawn  towards  the  uterus,  and  two  Kocher's  clamp  forceps  are 
applied.  The  ligament  is  divided  between  the  two.  Only  a  few 
minutes  are  thus  occupied.  Two  other  pairs  of  forceps  are  now 
passed  as  fur  as  the  upper  margin  of  the  bladder  in  an  oblique 
direction  inwards  towards  the  uterus,  and  the  peritoneum  divided 
between  these.  The  same  manceuvre  is  carried  out  at  the 
right  side.  The  linger  now  pushes  the  ureter  aside,  and  seeks  for 
the  uterine  vessels,  which  are  separated,  drawn  out,  and  clamped. 
Two  pairs  of  forceps  are  again  applied  at  either  side,  both  vessels 
being  thus  secured.     The  division  is  then  carried  on  as  far  as  the 


Fig.  345. — Six   Pairs   of  Kocher's  For- 
ceps   APPLIED    TO    THE    DIVIDED    BrOAD 

Ligament.    (Btjmm.) 


Fig.  3i6. — Kocher's  Forceps. 


fornix  of  the  vagina.  Should  the  posterior  cul-de-sac  have  been 
previously. entered,  the  anterior,  which  is  drawn  upwards,  is  opened 
through  this  aperture,  otherwise  the  finger  of  an  assistant  pushes 
the  anterior  fornix  upwards,  and  it  is  thus  incised.  A  fourth  pair 
of  the  forceps  now  take  in  the  divided  lateral  parts  of  the  vagina 
and  the  folds  of  Douglas,  the  incision  being  carried  on  between  the 
clamps.  The  uterus  is  now  completely  detached  and  removed. 
The  vaginal  wound  is  carefully  adjusted,  and  ligaturing  of  the 
broad  ligaments  is  proceeded   with  from  above  down,   the  thumb 


496 


DISEASES  OF    WOMEN. 


and  fourtli  finger  being  used  for  temporary  compression,  while 
the  ligation  is  made  with  thin  catgut.  Thus,  in  their  order,  the 
tubo-ovarian    vessels,    those    of    the    round    ligament,    the    uterine 


Fig.  347. — Bltjxt-pointed  Scissors. 

artei'ies  and  veins,  and,  lastly,  the  folds  of  Douglas,  are  secured.  The 
obliquely  running  wound  in  the  pelvic  peritoneum  is  closed  by  con- 
tinuous suture,  from  the  upper  angle  at  one  side  to  that  of  the 
other.     The  vagina  is  then  tamponed  loosely  with  gauze. 

Electrothermic  Hsemostasis. 

In  lieu  of  ligature,  clamp,  forci-pressure,  or  the  lever  ])ince  of 
Doyen,  the  method  of  angiotripsie,  or  forci-pressure,  introduced  by 
Skene,  of  Brooklyn,  in  which  pressure  by  heat  is  utilized  by  a 
special  forceps  or  clamp  heated  by  electricity,  has  been  more  gene- 
rally resorted  to  of  late  years.  These  special  advantages  are  claimed 
for  it :  *  the  tissues  do  not  slough,  and  it  enables  us  to  act  on  a  large 


Fig.  348. — Eleutku-H.^mostatic  Clajip  Forceps  of  Jacobs. 

surface,  including  the  tissues  that  separate  the  vessels  ;  it  is  clean 
and  rapid  in  its  action,  is  disinfectant,  permanent  in  its  effects, 
and  prevents  the  spread  of  infection,  while  it  lessens  the  chances  of 
adhesions.     >Skene  first  realized  the  principle  that  haemorrhage  can 

*  Jacobs,  Eerur:  de  Gynxcolor/ie,  July,  Aug.,  1899;  also  American  ( ri/n serology- 
July,  1903. 


UIEIilXE  XEOPLAi^M  fi— MYOMA— SURG  [CM    TREATMEST.     497 

be  controlled  by  the  modern  method  of  securing  the  vessels  as  they 
emerge  from  the  pedicles  under  the  peritoneum  by  means  of 
electrical  hjemostasis. 

Jacobs  uses  an  ordinary  forci-pressure  forceps,  one  of  the  branches  of 
which  has  its  blade  hollowed  so  that  the  interior  of  this  small  cavity  contains 
a  platinum  wire  completely  insulated  by  incombustible  material.  One  end  of 
the  wire  is  joined  to  the  blade  itself,  while  the  other  is  attached  to  an  insulated 
copper  wire  which  extends  for  the  length  of  the  forceps  to  its  handle,  where 
there  is  a  small  block  of  metal.  In  this  the  copper  wire  is  insulated,  and, 
passing  through  it,  ends  at  a  few  centimetres  from  it.  Another  short  copper 
wire  is  attached  to  the  block  close  to  the  handle.  The  instrument  can  be 
thoroughly  sterilized  and  then  used  like  any  other  forci-pressure  forceps. 
The  electric  current  passing  through  the  copper  wire  heats  the  platinum  in 
the  forceps  blade.  The  electricity  can  be  obtained  in  the  usual  manner  from 
the  ordinary  main,  and  a  rheostat  is  interposed  so  as  to  regulate  the 
strength  of  the  current  according  to  the  size  of  the  instrument  and  the  end 
there  is  in  view.  A  flexible  cable  enables  us  to  apply  the  instrument  at 
a  distance  from  the  electrical  source,  and  it  is  so  insulated  and  jointed  that 
the  termination  of  its  wires  is  duectly  continuous  with  those  of  the  instru- 
ment. The  idea  of  this  method  is  to  compress  between  the  blades  of  the 
forceps  a  part  of  the  tissues  adjacent  to  the  end  of  a  vessel,  expel  as  much 
blood  as  pos- 
sible, and  then 

secure         com-        ,  Pla-tlnum   eonneces  wi/th  Made 

plete   desicca-    ;  ''^'^  ^trf'^'^t  "^  '''"• 

■^  1  (fieiLtt/tf  Hade) 

tion     by     the     • 
heat  developed 
in  the  forceps. 
The  necessary 

temperature  is  — —    tnsuio.ir!on(MCca,       ^igction  of  Heating  Blade, 

a   heat  which 

neither  bruises  Fig.  3i9. — Dowxes'  ELECTKO-H.a:MOSTATic  Lever  Asgiotbibe.* 
nor  chars  the 

tissues.  The  instrument  can  be  sterilized  along  with  the  others  neces- 
sary for  an  operation.  When  applying  it  a  little  sterilized  vaseline  should 
be  smeared  along  the  blades  of  the  forceps,  so  as  to  prevent  adhesion  of 
the  tissues.  The  end  of  the  cable  can  be  sterilized  in  boiling  water  and 
then  wrapped  in  a  compress  of  sterilized  gauze.  In  applying  the  forceps 
the  tissue  immediately  joining  the  vessel  is  insulated,  so  as  to  avoid  the 
efiects  of  radiation ;  connections  are  now  completed,  and  the  current  is 
passed. 

Fig.  350  shows  the  cable  and  coupler  of  Downes.  A  rheostat  is  inter- 
posed so  as  to  regulate  the  strength  of  the  current  and  the  time  necessary  to 
produce  the  desiccation.     This  being  effected,  the  cun-ent  is  closed,  and  the 

*  All  the  previous  iBstrmnents  used  by  Jacobs  and  others  have  been 
superseded  by  those  of  Downes,  p.  i98. 

2   K 


CoTineeti  wlC/i  Transformer 
or  sCora-je  Battery 


498 


DISEASES   OF   WOMEN. 


tissue  which  extends  beyond  the  blades  of  the  forceps  is  cut.  The  forceps  is 
now  opened  cautiously  so  as  not  to  tear  the  tissues.  The  time  necessary  for 
the  desiccation  is  from  a  half  to  two  minutes.  According  to  Downes, '  a  com- 
plete electrothermic  outfit  consists  of  a  few  angiotribes  with  blades  of  different 
widths,  including  one  with  curved  blades,  the  shield,  the  cautery  knife,  the 
artery  forceps  heater,  the  cable,  the  electric  current  controllers,  consisting  of 
the  motor  transformer,  for  use  with  the  continuous  current,  and  a  transformer 
for  the  alternating  current.  With  this  outfit  and  a  sufficient  number  of 
ordinary  hsemostatic  forceps  any  hsemostatic  problem  in  surgerj'  can  be 
solved.' 

Looking  at  the  calibre  of  the  vessel  which  has  been  compressed,  it  has  a 
flattened  appearance  somewhat  resembling  parchment,  and  the  compressed 
tunic  becomes  translucent.  The  dried  portion,  after  it  has  been  well  soaked 
in  water,  remains  firm  and  unbroken,  and  any  dissection  of  the  component 
parts  of  its  tunics  is  impossible,  nor  can  we  recognize  its  various  elementary 
structures  with   the  microscope.      The  adjacent  tissues  undergo  the  same 


Fig.  350. — D.)wxes'  Sterilizable  Cable  to  Storage  Battery  with  Coupler. 

changes.  The  lumen  of  the  vessel  is  with  difficulty  determined.  Identical 
results  follow  the  application  of  the  instrument  to  the  vermiform  appendix, 
nor  can  any  trace  of  the  mucous  elements  be  found. 

Downes  (Philadelphia)  claims  special  advantages  for  his  modification  of 
the  electrothermic  angio tribe,  in  its  simplicity  of,  and  exactitude  in,  applica- 
tion. According  to  him,  '  pressure,  approximately  that  of  a  medium-sized 
angiotribe,  is  applied  to  the  tissue  to  be  hsemostased,  and  the  compressed 
ribbon  thus  formed  is  rapidly  submitted  to  a  temperature  of  not  under 
212°  Fahr.,  thus  coagulating  and  agglutinating  under  pressure  its  albu- 
minous constituents.  In  addition,  the  heat  even  travels  a  short  distance 
beyond  the  area  compressed  into  the  adjacent  tissue  and  causos  a  shrivelling 
of  the  intima  of  the  bloodvessel  leading  into  the  compressed  ribbon.  Clotting, 
therefore,  occurs  a  considerable  distance  beyond  the  ribbon.  The  possibility 
of  haemorrhage  after  proper  technique  is  inconceivable.' 

'  Hysterectomy. — In  vaginal  hysterectomy  for  benign  disease,  the  cervix  is 
encircled  by  the  cautery  knife  and  dissected  back  until  the  peritoneal  reflec- 
tions are  reached  and  the  abdomen  thus  entered.     The  fundus  is  brought  out 


UTEh'LSE   XEOl'J. ASMS— MYOMA-SURGICAL    Tl! EATMEST.      I'.IO 


through  the  anterior  incision  and  the  ^-inch  or  |-inch  blade  of  the  angiotribe 
apphed  to  the  broad  hganieut.  Sometimes  the  whole  broad  ligament  can 
be  included  in  one  gi-asp  of  the  blades,  but  usually  two  grasps  are  re()uired. 
The  first  should  be  ai)plicd  from  the  tubal  side  down,  to  include  the  round 


Figs.  8."i!. — Downks's  Electro-h^mostatic  Angiotribe.* 

ligament,  the  remainder  of  the  broad  ligament  should  then  be  included  in  a 
second  grasp.  The  shield  is  placed  around  the  blades  of  the  angiotribe  and 
the  current  turned  on  for  from  thirty  to  forty  seconds.  A  temporary  ha?mo- 
stat  is  apphed  to  the  uterine  side  of  the  broad  ligament,  section  made  along 
the  uterine  side  of  the  thermic  blade,  the  angiotribe  released  and  removed, 
exposing  a  white  ribbon  within  the  blades  of  the  shield.  On  removing  the 
shield  the  hEemostased  ribbon  shiinks  back  into  the  pelvis.     We  have  now 


Fig.  B52. — Electho-h^ejiostatic  Angiothibes,  Curved  and  Straight, 

WITH  Blades  i  or  |  inch  wide. 

Have  a  lever  at  end  of  handles  to  maintain  maximum  pressure.     Blades  released 

on  removal  of  lever. 

the  uterus  free  on  one  side  with  temporary  heeraostats  to  control  reflux  bleed- 
ing. Tlie  same  procedure  is  now  followed  on  the  opposite  broad  ligament, 
and  the  uterus  removed  by  section  along  the  uterine  side  of  the  thermic 
blades.  The  usual  toilet  of  the  peritoneum  can  then  be  accomplished.  In 
those  cases  in  which  hemisection  facilitates  removal,  the  cautery  knife  can  be 
used  in  place  of  the  scalpel,  and  the  angiotribe  then  applied  to  the  broad 
hgaments,  one  or  two  grasps  to  each.' 

For  mahgnant  disease,  in  suitable  cases  Downes  uses  the  following  method 

*  Am'-r.  Me<J..  Vols.  III.,  lY..  YI..  May  24,  1902  ;  Dec.  20,  1902  ;  Nov.  28, 1903. 


500 


DISEASES   OF    WOMEN. 


for  vaginal  hj'sterectomy :  '  The  cervix  is  encircled  by  the  cautery  knife 
through  the  mucous  membrane  quite  above  the  visible  evidence  of  disease,  and 
dissected  up,  using  the  cautery  for  searing,  until  one  and  a  half  inches  of  the 
cervix  is  exj)Osed,  or  until  the  level  of  the  internal  os  is  reached,  when  the 
cervix  is  amputated  by  the  cautery  knife.  The  cervical  canal  of  the  remain- 
ing uterus  is  thoroughly  burned  and  stuffed  with  gauze.  In  carrying  out  the 
foregoing  procedures,  should  any  paracervical  bleeding  occur  that  the  cautery 
knife  will  not  hsemostase,  the  bleeding  points  should  be  gi'asped  by  the  ordi- 
nary artery  forceps,  which  can  be  heated  by  applying  the  artery  forceps 
heater  to  their  tips  for  a  few  seconds.  In  some  cases  the  lower  branches 
of  the  uterine  artery  in  the  base  of  the  broad  ligaments  may  need  to  be 
hgemostased ;  in  these  the  tips  of  the  narrow-blade  angiotribe  are  very 
serviceable.  It  is  even  possible  without  opening  the  peritoneal  cavitj''  to 
apply  the  narrow  blades  along  the  sides  of  the  uterus,  so  as  to  occlude  the 
uterine  axievy.  After  removing  the  malignant  cervix,  the  vagina  is  resterilized 
the  peritoneal  reflections  are  entered,  and  the  remaining  portion  of  the  uterus 
removed  as  in  the  description  for  non-malignant  cases.  The  procedure  here 
advocated  is  aseptic  and  removes  the  danger  of  contamination. 


Fig.  353. — Downes'  Shield  for  surbounding  the  Blades.* 

'  In  malignant  cases  in  which  it  is  preferable  to  remove  the  uterus  through 
the  abdominal  incision,  the  preliminary  amputation  of  the  cervix  as  described, 
without  opening  the  peritoneal  reflections,  followed  by  the  removal  of  the 
remainder  of  the  uterus  through  the  abdomen,  renders  the  operation  free  from 
the  danger  of  implantation.  The  abdominal  part  of  the  operations  in  these 
cases  could  follow  any  known  technique  or  that  now  to  be  described. 

'Abdominal  Hysterectomy.— In  abdominal  supravaginal  and  panhj^sterec- 
tomies  a  variety  of  procedures  may  be  carried  out,  of  which  the  following  are 
types.  The  |-inch  or  |^-inch  blade  of  the  angiotribe  is  placed  on  the  broad 
lio-ament  from  outside  the  ovary  to  below  the  round  ligament,  the  shield 
applied,  the  current  allowed  to  act  for  about  forty  seconds,  a  temporary 
broad  ligament  forceps  applied  to  the  uterine  side,  and  section  made  along 
the  adjacent  side  of  the  thermic  blades.  The  angiotribe  is  removed  and  a 
wide  hsemostased  ribbon  is  seen  in  the  grasp  of  the  shield,  on  removal  of 
which  it  shrinks  toward  the  pelvic  wall.  The  same  procedure  is  carried  out 
on  the  opposite  ligament.  The  broad  ligaments  are  now  both  hsemostased 
and  sectioned  to  below  the  round  ligaments,  the  reflux  bleeding  from  the 


*  The  field  should  be  dried  aud  freed  of  blood  before  the  angiotribe  is  applied. 


UTEBINE   NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     ".01 


uterine  side  being  controlled  by  forceps.  The  bladder  is  next  freed  and  pulled 
forward  away  from  the  uterus.  This  puts  the  ureters  on  the  stretch  and 
makes  the  occlusiou  of  the  uterine  arteries  easier  and  safer.  The  next  grasps 
of  the  angiotribe  are  made  to  include  each  broad  ligament  from  below  the 
round  ligament  down  to  the  sides  of  the  cervLx;  so  as  to  include  surely  the 
uterine  arteries.  Section  is  made  on  the  uterine  side  of  the  blades,  and 
the  uterus  is  thus  released  so  that  on  upward  traction 
it  is  held  only  by  its  vaginal  connection,  in  which 
perhaps  are  the  vaginal  branches  of  the  uterine  arterj'. 
By  putting  the  vaginal  tube  on  the  stretch  it  is  easy 
to  include  progressively  small  portions  of  it  in  the 
narrow  blades,  and  thus  sever  the  uterus  bloodlessly 
by  section  through  the  vagina  below  the  cervix,  but 
above  the  blades ;  or  when  this  stage  is  reached  a 
curved  angiotribe  may  be  used  and  the  vaginal  tube 
clamped  in  one  bite. 

'  In  cancer  of  the  uterus,  when  entire  operation  is 
done  through  the  abdomen,  two  curved  clamps  can  be 
applied  below  the  cervix  to  occlude  the  vaginal  tube, 
the  loAver  one  being  electrothermic,  and  the  upper  any 
ordinary  cold  clamp.  On  section  between  these  curved 
blades,  the  vagina  is  occluded  below  the  cervix  so  that 
no  contamination  is  possible.  We  thus  carry  out 
Werder's  method,  using  electrothermic  hieraostasis  in 
place  of  ligatures.  If  the  operation  be  a  supravaginal 
hysterectomj",  after  the  occlusion  of  the  uterine  arteries 
section  is  made  across  the  cervix,  and  sutures  applied 
as  in  the  usual  operations.  Before  suturing,  the 
cauter}'  knife  should  sere  the  cervical  canal.  It  is 
possible  by  making  a  proper  wedge-shape  amputation 
at  the  cervix  to  use  an  angiotribe  with  blades  espe- 
cially devised,  that  would  easily  occlude  without  suture 
the  opposing  section  of  cervix.  The  technique  in  abdominal  or  vaginal  hyste- 
rectomy may  vary  from  the  above  description  in  that  the  wide  blade  if  used 
carefully  can  be  made  to  give  a  hfemostased  ribbon  in  the  broad  ligament 
through  which  section  can  be  made  without  the  necessity  of  temporary  clamps. 
If  this  be  done,  incision  through  the  broad  ligaments  can  be  absolutely  blood- 
less. In  using  the  broad  clamp  thus,  a  little  more  time  should  be  used  for 
the  cooking  process,  yet  not  enough  to  cook  so  thoroughly  that  the  tissues 
adhere  too  strongly  to  the  blades  of  the  angiotribe.  There  is  no  method  of 
hysterectomy  that  has  ever  been  performed  by  ligatures  in  which  we  cannot 
use  electrothermic  hsemostasis.  "We  can  begin  at  the  top  of  the  broad  liga- 
ment, go  down  one  side,  across  the  cervix,  and  up  on  the  other  side.  "We 
can  isolate  individual  arteries  and  ha^mostase  them  alone  by  pressure  and 
heat.  We  can  hemisect  the  uterus  from  the  abdominal  side  and  ha^mostase 
from  the  uterine  arteries  upward.  We  can  perform  Doyen's  operation, 
replacing  the  temporary  clamps  on  the  ovarian  and  uterine  arteries  by  the 
blade  of  the  amriotribe.' 


Fig.  35i. — ^Downes' 
Electro -thermic 
Cavtert  Kxife. 


502 


DISEASES   OF    WOMEN. 


We  have- another  good  example  of  the  effects  of  this  form  of  hsemostasis  in 
its  application  to  the  pedicle  of  an  ovarian  cystoma,  and  this  has  to  be  remem- 
bered, that  where  such  a  result  is  desirable  it  produces  an  occlusion  of  the 
lymphatics,  and  thus  opposes  an  obstacle  to  the  spread  of  infection ;  further, 
so  contracted  is  the  surface  of  the  divided  pedicle  that  it  does  not  offer  any 
bleeding  surface  calculated  to  contract  adhesion  with  surrounding  structures. 
In  those  cases  in  which  the  friability  of  the  tissues  renders  the  application 
of  a  ligament  difficult  and  risky,  electro-hajmostasis  is  complete  and  safe. 
Durmg   ovariotomy    and   hysterectomy,   if  there   be   omental   or  intestinal 


Fig.  355.— Applied  to  Ovai!1ax  Cy.stuma.     (Jacobs.) 

adhesions,  these  may  be  destroyed  by  a  quick  application  of  the  forceps,  and 
the  bleeding  of  small  vessels  controlled.  A  special  protective  shield  forceps 
is  used  by  Skene  and  Downes,  in  the  instance  of  intestinal  adhesions,  to  pro- 
tect the  coils  of  intestine ;  or  the  same  object  may  be  effected  with  gauze. 
The  applicability  of  tliis  method  to  the  pedicle  of  an  ovarian  cystoma  is 
obvious.  In  abdominal  total  hysterectomy  the  ordinary  hemostatic  forceps 
are  quickly  replaced  by  the  electrical .  forceps,  also  the  round  ligament  is 
secured.  A  minute  and  a  half  or  two  minutes  is  sufficient  for  the  ovarian  or 
uterine  arteries,  and  one  minute  for  the  roimd  ligament.     The   desiccated 


UTKlil.\J-:  XKOrLASMS—M YOMA—SUMOICAL    TJtEA  TMENT. 


:.o:5 


pedicles  are  covered  by  the  peritoneum  by  means  of  a  catgut  suture.  In 
salpiiigo-oophorectoniy  the  same  plan  is  pursued,  the  hiKniostatic  forceps  being 
replaced  by  the  electrical.  In  appendicectomy  in  unruptured  cases  the  ap- 
pendix and  meso-appendix  arc  included  in  one  bite  of  the  angiotribe,  and  then 
section  is  made,  and  the  purse-string  suture  is  applied  in  the  caecum  at  the 
base  of  the  sterile  stump,  which  is  invaginatc.  and  covered  over  by  peritoneum. 
In  other  cases  the  meso-apiiendix  is  first  hajmostased,  esi)ecially  when  there 


Fig.  356.— Electro-Hj<:mostasis  ix  Pax-Htsteeectomt.    (Jacobs.) 


has  been  rupture.     The  purse-string  suture  to  invaginate  the  sterile  stump  is 
always  a  necessity'. 

Jacobs  cites  a  case  in  which  he  resected  a  large  portion  of  the  omentum, 
and  instead  of  ligaturing  he  used  the  electrical  forceps,  with  perfect  control 
of  all  hfemorrhage.  He  argues  that,  even  if  an  operation  be  slightly  pro- 
longed beyond  the  time  occupied  by  the  simple  ligatures,  the  delay  is  com- 
pensated for  by  the  advantages  offered  by  the  method. 


50i 


DISEASES   OF    WOMEN. 


Downes  records  a  case  *  in  which  a  large  tubo-ovarian  suppurating  mass 
was  removed  and  four  inches  of  the  colon  resected  with  end  to  end  anasto- 
mosis, la  appendicectomy,  in  a  minute  and  a  half  to  two  minutes,  the 
application  of  the  forceps  allows  of  section  of  the  tissues  on  a  level  with  the 
instrumental  construction.  There  is  no  necessity  to  place  sutures  of  any 
kind,  nor  to  refold  the  pedicle  of  the  appendix  under  the  peritoneum.  The 
intestinal  mucous  membrane  is  united,  and  the  canal  of  the  appendix  is 
closed.  There  need  be  no  apprehension  in  returning  the  caecum  into  the 
abdomen.    These  advantages  are  claimed  for  the  use  of  electro -hsemostasis  over 


Fig.  357. — ELEOTKO-H.aaiosTASis  ix  Pan-Hysterectomy.    (Jacobs.) 

the  ligature  in  removal  of  the  appendix : — The  organ  is  divided  without  the 
escape  of  its  contents  on  the  adjacent  surfaces,  also  without  risk  of  perfora- 
tion or  abscess  of  the  wall  of  the  csecum  from  the  invagination  of  an 
infected  pedicle,  and  the  extension  of  the  infection  into  the  pedicle  between 
the  ligature  and  the  incised  end.  - 

In  vaginal  hysterectomy  the  forceps  used  are  longer  than  those  employed 
in  abdominal  hysterectomy,  so  as  to  enable  the  surgeon  to  obtain  greater 
security.  Further  than  the  substitution  of  the  electrical  for  the  ordinary 
forceps,  there  is  nothing  exceptional  in  the  operation. 

*  American  Gynecology,  July,  1903. 


CHAPTER   XXYII. 

UTERINE   NEOPLASMS— MYOMA    (continued)— 
SURGICAL   TREATMENT. 

Supra-vaginal  Hysterectomy. 

Kelly  thus  classifies  the  different  methods  of  performing  hysterec- 
tomy : — 

(1)  Ligature  of  ovarian  and  uterine  arteries  at  opposite  sides, 
with  supra-vaginal  amputation  (Freund). 

(2)  Ligature  of  ovarian  and  uterine  arteries  of  the  same  side, 
division  of  the  cervix,  ligature  of  the  uterine  and  ovarian  arteries 
at  the  opposite  side  (Pryor-Kelly). 

(3)  Exposure  of  the  cervix  posteriorly,  and  its  complete  division ; 
exposure  and  seizure  of  the  uterine  vessels,  or  the  clamping  of  the 
broad  ligaments  at  either  side,  with  or  without  the  ovaries,  and 
removal  of  the  uterus  (Faure). 

(4)  (a)  Anterior  exposure  of  the  cervix,  which  is  divided ;  the 
clamping  of  the  uterine  arteries ;  further  detachment  of  the  uterus, 
and  the  clamping  of  the  ovarian  vessels ;  or  (h)  the  clamping  of  the 
broad  ligaments  at  either  side  from  the  cornua  to  the  uterine 
arteries,  which  are  included,  with  subsequent  removal  of  the  tubes 
and  ovaries  (Kelly). 

(5)  Seizure  and  elevation  of  the  uterus  by  its  cornua,  and  its 
bisection  into  the  cervix  ;  division  of  one  half  of  the  cervix,  with 
exposure  and  control  of  the  uterine  arteries ;  traction  of  one  half 
of  the  uterus,  with  exposure  and  control  of  the  ovarian  vessels ; 
the  same  treatment  of  the  other  side  of  the  uterus  (Faure-Kelly- 
Kroenig). 

Method  of  Dealing  with  Complications  and  Adhesions. — These 
include  pelvic  abscesses,  vesical  and  rectal  adhesions,  and  embedded 
or  adherent  adnexa. 

In  all  these,  primary  bisection  of  the  uterus  is  availed  of,  so  as 
to  secure  easier  access  to  the  embedded  or  adherent  adnexa.  He 
attributes   to   the  newer  methods  the  following  advantages  :    The 


506 


DISEASES   OF   WOMEN. 


period  of  enucleation  is  shortened,  the  uterine  arteries  ai-e  more 
promptly  secured,  there  is  more  room  for  dealing  with  adherent 
adnexa,  the  whole  field  of  operation  is  more  open  to  view,  and 
greater  precision  and  security  is  secured. 

Supra-vaginal  Hysterectomy. — The  preliminary  steps  of  the  in- 
cision and  delivery  of  the  tumour  are  the  same  as  those  already 
described.  This  may  also  be  said  of  the  ligation  of  the  ovarian 
vessels  and  the  management  of  the  adnexa. 

Some  operators  do  not  remove  the  ovaries  if  thej'  be  healthy,  with  the 
object  of  preventing  the  disagreeable  symptoms  of  the  artificially  produced 
menopause.  This,  however,  will  depend  upon  the  condition  of  the  ovaries. 
Many  consider  that  it  is  sufficient  to  leave  one  ovary,  and  this  is  the  practice 
I  follow. 

The  tubo-ovarian  vessels  and  the  round  ligament  are  tied  sepa- 
rately.    It  is  safer  to  place  two  ligatures,  one  nearer  the  uterus, 


Ov  vas. 


P     r.dlig 


3l3.dd£ 


Fig.  358.- — A  Contintjous  Incision  from  Left  to  Eight,  ligating  or  clamping, 
AT  the  Points  indicated  by  the  Arrows,  the  Left  Ovarian  Vessels, 
THE  EouND  Ligament,  the  Left  Uterine  Artery.     (Howard  Kelly.) 

After  section  of  the  cervix,  the  uterus  being  drawn  to  the  right  side,  the  right 
uterine  vessels  are  exposed  and  secured. 

and  the  other  at  the  pelvic  side,  and  divide  the  broad  ligament 
between  these.  It  is  immaterial  whether  we  use  a  sharp-curvfed 
needle,  held  with  a  convenient  holder,  or  the  blunt  broad  ligament 
needle.     I    prefer   the   latter   for  the   broad   ligaments.     A   short 


utehim:  \/:ni'f.  \s\/s  -myoma    suimirM.   rin:.\ruKsr.    .".o" 

curved  needle  is  tlio  best  to  secure  the  uterine  artery  with.  It  is 
well,  however,  always  to  ha\e  at  hand  various  sizes  of  the  sharp 
needles,  as  well  as  those  of  Olshausen.  The  vesico-uterine  peri- 
toneum is  next  detached.  An  incision  is  cari'ied  from  one  round 
ligament  to  the  other,  and  the  bladder,  having  been  raised,  is  freed 
from  its  connection  with  the  uterus  by  being  pushed  down,  either 
with  a  gauze-dab  or  a  piece  of  sponge  held  in  the  holder.  The 
cervix  is  bared  as  far  as  the  vaginal  junction,  and  the  uterine 
vessels  at  either  side  come  into  view.  The  uterine  artery  is  now 
felt  for  at  the  left  side,  and,  with  a  sharp  curved  needle  passed 
close  to  the  uterus,  it  is  securely  ligated,  together  with  the  veins. 


Fig.  35!). — Tue  Timovu  cunxecteh  only  by  'jhk  Kounh  Ligamknt  and 
Eight  Adxexa.     (Howahi)  KELLY^) 

If  there  be  any  doubt  as  regards  the  security  of  the  ligature,  it  is 
well  to  draw  the  vessel  out  from  the  uterus,  and  place  a  second 
ligature  upon  it.  The  bi'oad  ligament  at  this  side  can  now  be 
divided,  the  scissors  being  made  to  skirt  the  margin  of  the  uterus, 
not  necessarily  enclosing  any  of  its  tissue.  Any  remaining  ^■essels 
that  bleed  ai-e  caught  and  rapidly  ligatured.  The  uterus  is  now 
held  up  by  an  assistant,  and  tilted  over  towards  the  right  side. 
But  little  blood  should  have  been  lost  up  to  this  part  of  the 
operation.  The  cervix  is  now  divided  a  little  aboA^e  its  junction 
with  the  vagina,  and  in  doing  so  the  uterine  canal  is  exposed.  This 
is  covered  by  some  folds  of  sterilized  gauze,  and  the  severance  of 
the  uterus  is  completed  up  to  the  exposure  of  the  opposite  uterine 


508 


DISEASES   OF   WOMEN. 


vessels,  which  are  seen  at  the  right  border  of  the  cervix,  and  a 
little  distance  from  it.  The  uterus  is  now  drawn  up,  so  as  to 
separate  the  cut  surfaces,  and  thereby  the  vessels  at  the  right  side 


Fig.  360. — Sagittal  Section  of  L akge 
Myomatous  Tumour.  (Howard 
Kelly.)  * 

The  uterus  in  this  case  is  at  the 
bottom  of  the  tumour,  which  ex- 
tended to  the  pelvic  floor.  The 
tumour  had  undergone  central  ne- 
crosis and  suppuration,  opening 
through  an  antevertebral  abscess 
into  the  transverse  colon.  There 
were  extensive  omental  adhesions 
on  the  face  of  the  tumour,  which 
were  freed  by  leaving  a  thiu  layer 
of  the  latter  attached  to  them. 
Haemostasia  of  the  pelvic  vessels  was 
facilitated  by  an  autro-posterior 
section  of  the  cervix  after  previous 
clamping  of  the  broad  ligaments, 
and  the  transverse  section  was  then 
completed.  During  the  operation  a 
litre  of  i^us  escaped  from  the  abscess. 


Fig.  361. — Sagittal  Section  of  a 
Myoma  treated  by  Median  Bi- 
section OF  the  Tumour  and  Uterus. 
(How^\RD  Kelly.)* 

In  this  case  the  ovarian  and  uterine 
vessels  were  sjjread  over  the  summit 
of  the  tumour,  on  which  lay  the 
fundus  uteri.  The  growth  was  re- 
moved by  bisection  of  the  uterus 
iind  tumour,  each  half  of  the  tumour 
being  enucleated.  When  the  ute- 
rine vessels  were  ligated,  the  halves 
of  the  uterus  were  also  enucleated, 
and  the  bed  of  the  tumour  closed  by 
buried  sutures,  the  patient  making 
an  excellent  recovery. 


Amer.  Jour.  Ohstet.,  Sept.,  1900. 


UTERINE   NEOPLASMS— jVrO.y A- SUh-(;/CA/.    THEA  TMKKT.     oOO 


are  more  completely  exposed.  The  uterine  artery  first,  the  round 
ligament  secondly,  and  the  ovarian  vessels  last,  are  each  secured 
with  Kocher's  forceps,  and  when  the  broad  ligament  has  been 
divided  the  tumour  can  be  removed.  The  tubo-ovarian  vessels  and 
the  round  ligament  are  now  tied,  the  uterine  artery  being  dealt 
with  last.  After  careful  wiping  of  the  peritoneal  surfaces,  and 
examination  of  the  pelvic  cavity,  so  as  to  secure  any  remaining 
vessels  that  may  require  ligature,  the  cervical  stump  is  examined 
and  dried,  the  canal  is  wiped  out  with  a  small  I'oll  of  gauze  wet 
with  formalin  solution,  and,  if  there  be  reason  to  fear  infection  from 
the  nature  of  any  secretion  it  contains,  a  uterine  wool-holder  is 
dipped  in  carbolic  acid,  and  carried  a  short  distance  into  the  canal. 
The  surface  of  the  cervical  stump  is  now  fashioned  so  as  to  permit 
of  the  anterior  peritoneal  flap  being  drawn  forwards  over  the  stump, 
and  attached  to  the  posterior  peritoneum  from  side  to  side  by  con- 
tinuous catgut  suture.  The  ends  of  the  round  ligament  and  the 
ovarian  pedicles  are  turned  in  between  the  peritoneal  layers,  and 
now  the  two  layers  of  peritoneum  are  united  together  from  side  to 
side  of  the  pelvis  in  a  line  running  from  one  ovarian  pedicle  to  the 
opposite.  Nothing  now  remains  but  to  complete  the  peritoneal 
toilet  and  close  the  abdominal  wound. 

Zweifel,  in  supra- vaginal  hysterectomy,  when  feasible  enucleates  the  tumour 
from  its  capsule,  and,  having  clone  so,  secures  the  round  and  broad  ligaments 
either  with  his  angiotribe  or  ligatures.  In  closure  of  the  abdominal  wound 
where  the  latter  is  large,  lie  first  passes  three  or  four  deep  gut  sutures  tln-ough 
all  the  structures  save  the  skin,  using  the  needle  as  shown  in  Fig.  .390.  The 
ends  of  these  sutures  are  allowed  to  hang  at  either  side  of  the  wound  until 
the  other  suturing  in  layers  is  completed,  and  then  they  are  tied  up.  In 
cases  where  the  abdominal  incision  has  to  be  considerably  extended,  oi- 
in  which  from  emergency  or  urgency  the  triple  suture  cannot  be  carried  out, 
three  such  sutures,  applied  at  intervals,  will  be  found  to  diminish  considerably 
tlie  tension  on  the  other  sutures. 

Zweifel's  Angiotribe.— Zweifel,  in  vaginal  hysterectomy  and  pan-hysterec- 
toni}',  as  also  in  myomectomy,  uses  a  powerful  angiotribe,  the  nature  of 
which  can  be  readily  understood  from  the  illusti-ation.  It  is  used  much  in 
the  same  manner  as  Doyen's  instrument,  the  crushing  power  of  the  blade 
being  multiphed  three  times.  Zweifel  does  not  trust  to  it  alone.  He  uses  a 
Paquehn's  cautery  to  the  divided  surface,  and  resorts  to  ligatures  of  chromi- 
cized  cumol  gut.  He  employs  it  both  in  vaginal  and  abdominal  hysterectomy. 
In  his  vaginal  operation  he  closes  the  peritoneum,  and  turns  out  the  stumps 
in  the  same  fashion  as  does  Leopold. 

Noble  thus  admirably  described  the  method  of  dealing  with  that  very 
commonly  met  with  complication,  viz.  the  opening  up  of  one  or  both  broad 
liganients  bv  the  tumour :  '  In  such  a  case  the  method  of  Kellv  or  that  of 


510 


DISEASES   OF    WOMEN. 


Pryor  can  he  adopted.  The  ligation  is  made  in  the  usual  way  on  the  easy  side. 
Then  the  ovarian  vessels  upon  the  involved  side  are  secured.  The  relations 
of  the  upper  border  of  the  broad  ligaments  may  be 
entirely  distorted  by  the  intra-ligamentous  development 
of  the  tumour,  but  the  vessels  can  be  found  and  ligated 
without  difficulty.  When  spread  out  over  the  tumour, 
they  are  best  picked  up  (especially  the  veins)  by  passing 
a  blunt  aneurism  needle  under  them.  The  round  liga- 
ment may  be  widely  separated  from  the  ovarian  vessels. 
A  separate  ligature  is  placed  to  secure  the  vessels  of 
the  round  ligament.  Clamps  are  placed  to  control 
reflux  hfemorrhage.  The  round  ligament  is  then  cut 
through,  and  the  peritoneum  in  front  of  the  tumour  is 
incised,  and  the  incision  is  carried  across  the  front  of 
the  uterus  to  the  opposite  side.  The  bladder  is  then 
pushed  down,  and  the  peritoneum  is  pushed  off  the 
anterior  face  of  the  tumour.  Careful  search  is  made 
for  the  ureter,  as  in  such  cases  it  may  run  over  the 
anterior  face  of  the  tumour.  (He  has  never  found  it 
in  this  location.)  The  ovarian  vessels  are  next  divided, 
and  the  peritoneum  is  incised  on  the  posterior  face  of 
the  tumour.  The  tumour  is  then  enucleated  by  making 
traction  upon  it  with  the  hand  or  with  vulsellum  forceps, 
and  by  pushing  the  peritoneum  and  connective  tissue 
off  from  the  tumour  with  a  sponge.  At  this  stage  all 
vessels  have  been  secured  except  the  uterine  artery 
upon  one  side,  and  if  the  tumour  be  peeled  out  of  its 
bed  by  pushing  the  connective  tissue  away  with  a 
sponge,  no  haemorrhage  results.  After  enucleation  and 
delivery  of  the  tumour,  the  uterine  vessels  upon  the  involved  side  can  be 
ligated  in  the  usual  way.' 

When  both  broad  ligaments  are  distorted  by  iutra-ligamentous  development 
of  the  tumour  or  tumours,  temporary  ligatures  are  placed  internal  to  the 
ovaries  upon  both  sides  to  control  haemorrhage  from  the  ovarian  arteries. 
'  By  placing  clamps  near  the  horns  of  the  uterus  to  control  reflux  hsemorrhage, 
the  upper  border  of  the  broad  ligaments -can  be  cut  through,  and  the  vessels 
of  the  round  ligaments  secured  in  the  usual  way,  and  the  tumours  enucleated 
by  traction  and  pressure  with  a  sponge  as  already  described.  After  delivery 
of  the  tumours,  ligation  of  the  uterine  vessels  is  simple.  The  cervix  is  then 
amputated  and  closed.  Permanent  ligatures  are  placed  external  to  the  ovaries, 
and  the  appendages  are  removed.  Finally,  the  peritoneal  flap  is  sutured  in 
the  usual  manner.  This  method  is  especially  valuable  when  the  tumour  is 
impacted  in  the  pelvis,  and  the  appendages  are  densely  adherent  beneath  the 
tumour.' 

Baer's  Supra-vaginal  Method. 

In  Baer's  operation,  by  transfixion,  ligation,  and  cutting,  assisted  by  the 
control  of  clamp  forceps,  the  broad  ligaments  are  severed  at  both  sides  from 


Fig.  362.— Zwei- 

FKL's    AXGIOTKIBE. 


I'TEIUSE   XEO PLASMS— MYOMA — iURGlCAJ.    riiLATMLM.     :>11 

the  tumour  to  a  short  distance  from  the  cervix.     The  knife  is  then  carried 
lightly  around  tlie  tumour  in  front  and  behind,  an  inch  or  two  above  the 


Fig.  3tj3. — Shuws  tuk  Ov.\kiax,  Round  Liga- 
ment, AND  Uterixk  Arteries  ligated  by 
Isolated  and  Mass  Ligatures.    (Noble.) 

The  exposed  surface  of  the  cervical  stump  is  seen 
cupped,  and  as  yet  uncovered  by  the  peritoneal 
flaps. 


■:W-^' 


Fig.  301. — Shows  the  Round  Ligament,  Ovarian,  and  Uterine  Arteries 

LIGATED  BY  AX  ISOLATED  AND  MaSS  LiGATURE.   (NoBLE.) 

The  cervical  stump  is  closed  once  by  interrupted  sutures;  the  peritoneal  wound 
at  the  left  side  is  closed  by  Lembert  suture. 


512 


DISEASES   OF   WOMEN. 


peritoneal  reflexion  of  the  bladder,  and  the  peritoneum  stripped  off  with  a 
scalpel  handle  for  the  purpose  of  making  peritoneal  flaps.  The  next  step  is 
the  ligation  of  the  uterine  arteries.  This  is  accomplished  by  passing  the 
ligature  through  the  broad  ligament,  outside  of,  but  close  to,  the  cervix, 
avoiding  the  ureters.  The  uterus  is  then  amputated,  and  the  stump  (trimmed 
and  made  as  small  as  possible)  immediately  recedes  upon  being  released,  and 
is  buried  out  of  sight  by  the  peritoneal  flaps  which  cover  it  like  elastic  bands. 
The  peritoneal  flaps  are  united  by  Lembert  sutures,  if  necessary.  The  cervix 
is  thus  allowed  to  resume  its  natural  position,  and  is  devoid  of  a  single 
ligature  or  suture  in  its  tissues.  Nothing  whatever  is  done  to  the  cervical 
canal.  Nor  has  Baer  found  it  necessary  to  use  the  temporary  elastic  ligature 
about  the  cervix. 

Complications   met   with  in  Supra-vaginal  Hysterectomy. — Howard  Kelly 
classifies  these  thus  : — 

Tliose  due  to  adhesions  to,  and  affections  of,  the  surrounding  structures ; 
those  brought  about  hy  changes  in  the  tumours  themselves ;  those  due  to  the 

position  of  the  myo- 
matous mass ;  those  due 
to  pregnancy,  ascites, 
and  other  causes  in  par- 
ticular. 

The  first  class  in- 
cludes those  affections 
of  the  ovaries  and  Fal- 
lopian tubes  which  are 
likely  to  cause  adhesions 
of  the  omentum,  pa- 
rietes,  rectum,  sigmoid, 
colon,  small  intestines, 
vermiform  appendix, 
liver,  and  suspensory 
hgament.  It  also  in- 
cludes diseased  states  of 
the  ovaries,  as  well  as 
diseases  of  the  cervix 
and  uterine  mucosa,  any 
of  which  may  give  rise 
to  adhesion.  As  re- 
gards the  changes  in 
the  tumours  themselves, 
these  include  cysto  - 
myoma,  telangiectasis, 
suppurating  myoma, 
and  adeno-myoma. 
Amongst  the  principal 
complications  due  to  the 
position  of  the  tumour, 
are  high  displacements  of  the  tubes  and  ovaries,  filling  and  wedging  of  the 


Fig.  365.- 


-TcMOUR  WITH  Omental  Adhesions. 
(HowAED  Kelly.) 


UTERINi:    X KO PLASM S—MYOMA—SUR(!  ICA  L    TUEA  TMENT.    r.l3 


pelvis,  alteration  in.the  position  of  the  vesical  and  posterior  pelvic  peritoneum, 
broad  ligament  myoma,  displacement  of  the  ureters,  and  other  unusual  de- 
velopments of  the  rayomata  in  different  directions.  With  regard  to  the  third 
class,  there  is  the  myoma  which  complicates  pregnancy,  and  those  cardiac 
nephritic  and  ascitic  conditions  tliat  complicate  myoma.  If  there  be  an 
adherent  sigmoid  flexure  with  inflammatory  and  diseased  conditions  of  the 
left  tube  and  ovary,  and  the  latter  are  difficult  to  reach,  cither  because  they 
are  sheltered  by  the  tumour,  or  wedged  down  in  the  pelvis,  and  the  adhesions 
dangerous  to  separate,  being  out  of  sight,  the  enucleation  is  begun  by  seeking 

out  the  ovarian  vessels  at  the  outer  ex-    .       _  _  

tremity  of  the  broad  ligament,  and  tying 
at  two  points ;  then  cutting  between  them, 
and  tying  off  the  round  ligament  in  the 
same  way.  The  top  of  the  broad  ligament 
is  thus  opened  up,  and  the  uterus  can  be 
lifted  out  so  as  to  allow  a  free  access  to  the 
inflamed  structures.  If  pus  be  present,  it 
must  be  carefully  removed  in  the  usual 
manner  by  protection  of  the  parts  and 
aspiration. 

Omental,  parietal,  and  iutestinal  ad- 
hesions have  to  be  treated  in  the  ordinary 
mamier  by  careful  detachment  and  liga- 
ture. 

If  the  vermiform  appendix  be  adherent, 
and  the  adhesion  slight,  it  may  be  peeled 
off;  but  if  dense,  with  evidence  of  past 
or  co-existing  appendicitis,  Kelly  cuts  the 
tumour  across  the  cervix,  having  freed  it 
on  the  left  side,  clamps  the  right  uterine 
artery,  rolls  the  tumour  out,  and,  having 
secured  the  right  round  ligament  and 
ovarian  vessels,  clamps  off  the  appendix 
near  the  colon,  leaving  it  attached  to  the 
tumour,  and  subsequently  dealing  with  its 
stump. 

If  there  be  tumours  of  the  ovary  com- 
plicating the  myomata,  these  must  be  dealt 
with  according  to  the  individual  pecu- 
liarities of  the  case,  the  ovarian  tumour 
and  fibroma  being  removed  together. 

Should  cancer  of  the  cervix  be  present, 
or  malignant  conditions,  such  as  adeno- 
carcinoma, of  either  the  cervix  or  body,  it 
is  better  to  perform  pan-hysterectomy. 

If  the  tumour  be  fibro-cystic,  and  there  be  much  fluid  in  the  cyst,  this  may 
be  tapped,  and  the  operation  then  proceeded  with. 


Fig.  366.  —  Neckosed  Mass, 
WHICH,  WITH   Ligatures,  was 

PASSED  THROUGH  THE  Os  UtERI 

after  Supra-vaginal  Hyste- 
rectomy ON  THE  Twenty- 
fourth  Day,  leaving  the 
Vaginal  Vault  PERFECT.  (Na- 
tural Size.) 

There  had  been  an  oftensivc  va- 
ginal discharge,  but  uo  con- 
stitutional symptoms  whatever. 
The  mass  came  away  when  the 
vagina  was  being  douched  at 
night.  The  patient  made  a 
perfect  recovery.     (Author.) 


514  DISEASES   OF    WOMEN. 

The  More  Serious  Complications  in  Hysterectomy. 

With  regard  to  the  serious  complications  the  surgeon  has  to  deal  with  in 
the  removal  of  myomata,  viz.  unusual  and  dangerous  developments,  either 
with  reference  to  the  space  occupied  in  the  pelvis,  or  the  relations  of  the 
tumours  to  the  peritoneum  and  the  pelvic  viscera,  the  management  of  all 
such  must  depend  upon  the  exact  condition  met  with  at  the  time.  The 
lines  of  procedure  in  various  cases  will  be  iniluenced  by  {a)  the  difficulty 
in  delivery  of  the  tumour ;  (6)  the  freeing  of  adhesions ;  (c)  the  position  of 
the  bladder  with  regard  to  the  tumour;  {d)  the  involvement  and  displacement 
or  di\asion  of  the  broad  ligaments  and  the  adnexa  ;  (e)  the  pelvic  attachments, 
and  the  firmness  of  adhesions  and  degree  of  impaction  of  the  mass  ;  (/)  the 
displacement  of  the  ureters,  or  the  presence  of  adhesions  which  either 
sun-ound  them  or  bring  them  into  close  relation  to  the  uterine  arteries  or 
branches  of  these  vessels ;  {g)  the  relation  of  the  tumour  to  the  sigmoid  or 
rectum,  and  the  presence  of  adhesions  uniting  the  tumour  to  the  bowel. 

Post-Operative  Haematemesis. — In  speaking  of  post-operative  hsematemesis, 
Halliday  Groom  *  says  :  '  In  a  number  of  cases  where  haematemesis  occurred 
which  I  have  taken  from  my  note-book,  I  find  that  eight  out  of  ten  died,  and 
that  the  hsematemesis  continued  from  the  end  of  the  first  forty-eight  hoiirs 
till  death  ensued.  From  my  own  cases  I  should  be  inclined  to  agree  with 
the  writer  of  a  recent  paper,  who  states  that  age  has  no  influence  on  the 
incidence. 

'  Many  theories  have  been  advanced.  One  is  that  it  results  from  the 
administration  of  an  anaesthetic,  but  considering  the  frequency  with  which 
anaesthetics  are  given  and  the  comparative  rarity  of  hfematemesis,  I  think  we 
may  put  this  out  of  court.  Again,  it  has  been  said  that  it  is  due  to  handling 
the  stomach  and  duodenum,  but  in  most  of  the  cases  occurring  in  my  own 
experience  the  stomach  and  duodenum  have  not  been  interfered  with.  The 
theory  of  Von  Eiselsberg  is  that  it  is  due  to  thrombosis  of  the  omental  vessels 
after  ligature  or  injuiy,  followed  by  embolism  in  the  wall  of  the  stomach  and 
the  formation  of  ulcers. 

'  So  far  as  my  personal  experience  is  concerned,  I  am  disposed  to  think 
that  most  cases  of  haematemesis  after  abdominal  operation  are  due  to  sepsis. 
Sepsis,  we  know,  could  produce  congestion  and  small  haemorrhages  in  the 
mucous  membrane,  and  whether  sepsis^  be  the  actual  cause  or  not,  in  my 
experience  at  least,  the  phenomenon  was  usually  observed  in  cases  which  did 
ultimately  succumb  to  sepsis  in  some  form  or  other. 

'  "Whatever  the  cause,  I  have  no  hesitation  in  saying  that,  in  abdominal 
sections  at  least,  haematemesis  is  one  of  the  most  serious  complications  which 
can  occur.'  f 

*  Brit.  Gyn.  Jour.,  May,  1902. 

t  In  the  British  Gynxcolojical  Journal  of  1902,  a  case  of  coffee-ground  vomit- 
ing'with  haematemesis  after  hysterectomy,  in  a  patient,  aged  41,  is  recorded  by 
me.  There  were  no  evidences  of  sepsis  either  in  pulse,  temioerature,  or 
respirations,  until  on  the  fourth  day  the  coffee-ground  vomiting  occurred.  The 
abdomen  was  opened,  but  nothing  was  found  to  account  for  the  bleeding.  It 
continued  notwithstanding  everj-  means  used  to  arrest  it. 


CHAPTER   XXVITT. 

UTERINE    NEOPLASMS— MYOMA— SURGICAL 
TREATMENT  (continued). 

Vaginal  Hysterectomy  by  Ligature  and  Angiotripsy. 

Vaginal  Hysterectomy  by  Ligature. — Looking  at  the  exceptions 
which  have  been  enumerated  in  regard  to  the  indications  for  vaginal 
hysterectomy,  it  is  not,  speaking  generally,  prudent  to  attempt  to 
remove  myomata  by  the  vaginal  route  save  in  a  relatively  small 
proportion  of  cases.  This  conclusion  is  the  more  true  since  the 
value  of  the  operations  of  myomectomy,  with  or  without  morcellation, 
has  come  to  be  realized.  The  two  most  complete  operations  for 
small  interstitial  and  subperitoneal  myomata  are  those  of  enu- 
cleation, either  by  colpotomy,  posterior  or  anterior,  or  abdominal 
coeliotomy.  In  the  case  of  obese  women,  where  vaginal  hysterectomy 
is  feasible,  the  removal  of  the  tumour  by  this  route  is  preferable. 
Also,  in  tumours  of  a  given  size  in  which  unilateral  adnexal  cysts, 
solid  tumours  of  the  ovary,  or  simple  tubal  distensions  complicate 
the  growth,  the  vaginal  method  may  be  selected.  The  adnexal  cyst 
tumour,  or  dilated  tube,  is  first  dealt  with,  and  then  the  uterus  is 
removed  with  comparative  ease. 

Operation. — In  proceeding  to  perform  vaginal  hysterectomy  for 
myoma,  when  hsemostasis  by  ligature  is  the  method  to  be  followed, 
it  is  well  also  to  have  at  hand  some  vai"ious-sized  clamp  forceps  or 
pressure  forceps,  for  temporary  hsemostasis,  or,  should  some  in- 
superable difficulty  arise  in  controlling  haemorrhage,  it  may  be 
necessary  to  resort  to  forcipressure  by  the  clamp,  which  is  allowed 
to  remain. 

Every  aseptic  precaution  having  been  taken,  and  the  vagina 
thoroughly  sterilized,  the  woman  is  placed  in  the  usual  position, 
the  buttocks  being  brought  well  over  the  edge  of  the  table,  and  the 
thighs  widely  apart.  The  operator  sits  in  front  of  the  patient ; 
an  assistant  stands  at  either  side,  and  another,  or  a  nurse,  takes 


516 


DISEASES   OF   WOMEN. 


control  of  the  instruments,  ligatures,  and  sutures,  while  a  second 
nurse  has  charge  of  the  dabs,  etc. 

Should  leg  rests  not  be  at  hand,  nor  a  hysterectomy  table,  the 
assistant  at  either   side   supports   the  thighs  by  slipping  one   arm 

under  the  knee  of  the 
patient,  holding  it  up 
and  out,  leaving  his 
other  hand  free  to  assist 
with  dabs  or  instru- 
ments. With  a  full- 
sized  Martin's  retractor, 
the  posterior  wall  of 
the  vagina  and  the  peri- 
neum are  drawn  well 
back,  and  so  held  by 
an  assistant.  The 
empty  bladder  is  ex- 
plored with  the  sound,  and  its  relation  to  the  uterus  and  vaginal 
cul-de-sac  determined.  The  flushing  retractor  (Fig.  105)  is  most 
useful  for  the  anterior  cul-de-sac.  It  enables  a  constant  stream 
of  sterilized  water,  to  which  some  lysoform  is  added,  to  be 
directed  over  the  parts.  The  assistants  keep  control  of  the  outlet 
at  either  side  by  means  of  lateral  retractors.  The  cervical 
lips  at   either  side   are  now  seized   with  single  tenacula,  both  of 


Fig.  367. — Preliminary  Incision  round  Cervix. 


Figs.  368,  369,  370.— Claw  Forceps. 

which  are  grasped  in  one  hand.  The  uterus  is  drawn  down  as 
far  as  possible,  and  a  circular  incision  is  made  round  the  cervix  a 
short  distance  below  the  vaginal  fold.  The  mucous  membrane  is 
now  carefully  raised  and  pushed  away  with  the  index  finger.    When 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     517 


this  has  been  effected  the  posterior  fold  of  peritoneum  is  sought  for, 
and  is  caught  with  the  forceps  and  opened  with  scissors.  The 
opening  is  enlarged  by  diverging  the  blades  of  the  scissors,  and  with 
the  finger.  Tlie  tenacula 
being  firmly  held  in  the  left 
hand,  the  right  forefinger 
nail  is  now  introduced  under- 
neath the  anterior  mucous 
.fold,  and  this  is  stripped 
thoroughly  from  the  uterus, 

thus  at  the  same  time  detaching  the  bladder,  ha^•ing  again  deter- 
mined its  relation  to  the  uterus  with  the  sound.  The  conical  retractor 
of  Martin  is  now  passed  anteriorly  under  the  mucous  membrane, 


Fig.  371.— O'Sulltvan's  Uteiunk  Tkactoi;. 


Fig.  372. — Detacitment  of  the  Bladder  by  the  Fingeu  after  the  Opening 

OF    THE    AnTERIOK    CuL-DE-SAC.       (DoTEX.) 

and  the  peritoneal  reflexion  in  front  is  carefully  sought  for.  "With 
a  dressing-forceps  and  blunt-pointed  curved  scissors,  this  will  be 
found    with    but    little    difficulty.     When    it    is   drawn   down  and 


518 


DISEASES   OF   WOMEN. 


opened  with  the  scissors,  the  opening  being  enlarged  by  diverging 
the  blades,  it  is  further  freed  by  running  the  point  of  the  fore- 
finger from  side  to  side  of  the  aperture.     The  anterior  peritoneal 


Fig.  373. — IMaktix's  Eeteactor. 

edge  is  now  sutured  to  the  border  of  the  vaginal  mucous  membrane, 
by  a  continuous  or  interrupted  gut  or  silk  suture.     The  uterus  is 


Fig.  374. — Laege  Eeteactor  or  Maetix,  to  protect  the  Bladder. 

drawn  to  the  right  side,  and  a  finger  is  passed  by  the  side  of  the 
cervix    as  far  as   the  lower   border  of  the   broad  ligament.     The 


Fig.  375. — Maetix's  Large  Perineal  Eeteactoe. 
Both  the  above  retractors  are  useful  also  in  colpotomy. 

pulsating  uterine  artery  is  now  felt  for,  and  a  curved  Olshausen's 
needle  (Fig.  329)  is  carried  close  to  the  cervix,  and  the  artery 
is  ligatured.    If  the  uterus  be  high,  and  any  difficulty  be  experienced 


UTERINE   NEOPLASMS— MYOMA — ^UIVilCAL    THE  ATM  EST.     5l'J 

in  securing  the  ligature,  the  tightener  of  Ehrenfest  (Fig.  387)  raay 
be  used  to  secure  it.  The  threads  of  the  ligature  are  passed  into 
the  grooves  at  the  extremity  of  the  instrument,  and  are  brought 
down  and  fixed  in  the  slot,  which  is  easily  opened  by  slight  pressure 
with  the  lingers.  By  compressing  the  handles  the  blades  diverge, 
and  thus  the  iirst  loop  of  the  knot  is  tightened.  The  instrument 
is  withdrawn,  and  the  knot  is  completed. 

There  is,  however,  very  little  difficulty  as  a  rule  in  securing  the 


Fig.  376. — Lateral  Ketkactor. 

uterine  vessel,  the  important  point  being  not  to  pass  the  needle  too 
far  from  the  side  of  the  cervix,  in  order  to  avoid  including  the 
ureter.  A  scissors,  curved  on  the  flat,  with  fairly  broad  blades,  is 
now  passed  close  to  the  uterine  wall,  and  the  ligament  is  detached  by 
cutting  close  into,  or  even  including,  a  portion  of  the  uterine  tissue. 
Another  ligature  is  now  passed  in  the  same  way  above  the  first,  and 
further  section  of  the  ligament  is  completed.     A  third  ligature  is 


Fig.  377. — Olshausen's  Needle-holder.     (^  size.) 

This  is  an  admirable  needle-holder — it  is  light,  of  sufficient  length  to  catch 
sutures  or  ligaments  deep  in  the  pelvis,  and  easily  manipulated. 

generally  required  for  further  detachment  of  the  broad  ligament. 
We  have  now  arrived  near  its  upper  border,  around  which  the 
finger  is  hooked,  drawing  into  view  the  tube  and  ovary  of  that  side. 
If  these  be  healthy  they  may  be  left,  at  least  at  one  side.  The 
upper  portion  of  the  ligament  is  firmly  secured  before  its  division, 
sufficient  pedicle  being  left  to  provide  against  the  slipping  of  the 
ligature.     If,  on  the  other  hand,  the  adnexa   be  removed,  these 


520 


DISEASES   OF    WOMEN. 


must  be  drawn  well  down,  and  the  ligatvire  passed  between  these 
and  the  pelvic  wall.  The  broad  ligament  having  now  been  com- 
pletely severed,  the  uterus  is  hooked  forward  by  the  volsella  or  the 
finger,  and  the  broad  ligament  of  the  opposite  side  is  ligatured  in 
like  manner  to  its  fellow  from  above  down ;  or  the  same  proceeding 


Fig.  378. — Maetin's  Needle-holuek. 
An  excellent  needle-holder  in  vaginal  operations. 

may  be  adopted  as  before,  and  the  uterine  arteries  secured  first. 
The  uterus  is  now  completely  detached,  and  we  proceed  to  examine 
all  bleeding  points,  and  to  secure  these  finally  with  ligature,  not 
ceasing  as  long  as  there  is  any  escape  of  blood,  no  matter  how  slight. 
Should  some  high-placed  vessel  resist  our  efforts,  and  there  be  still 


Fig.  380. — Fexestkated  Eeteactoe. 

trickling  or  oozing,  it  is  better  to  resort  to  forcipressure  rather  than 
take  the  chance  of  post -operative  haemorrhage.  Any  protruding 
loop  of  intestine  or  omentum  is  cautiously  pushed  back,  and  the 
severed  tissues  and  peritoneum  are  carefully  but  gently  dried  with 
sterilized  gauze,  and  a  final  examination  is  made  for  any  bleeding 


UTERINE  XEOPLAS}fS—MrO.VA—SlIEGICAL    TREATMENT.     521 

point.  Should  a  ligature  seem  to  be  dangerously  loose,  or  a  pedicle 
cut  too  close,  it  is  better 
to  re-secui*e  it.  In  short, 
remembering  that  the 
principal  dangers  of  va- 
ginal hysterectomy  are 
inclusion  of,  or  injury  to, 
the  uretei",  and  haemor- 
rhage from  insecure  liefa- 


FiG.  381. — Olshausex's  Retkactor. 

(J  NAT.    SIZE.) 


tion  of  an  artery,  or  loose  tying  of  a  pedicle,  it  is  obvious  that  too 


Fig.  382. — Division  uf  the  Anterior  Wall  of  the  Uterus  after  the 
OPEyixG  OF  the  Anterior  Cul-de-sac.     (Dotex.) 


522 


DISEASES   OF    WOMEN. 


great  care  cannot  be  taken  so  as  to  avoid  the  former  or  to  protect 
our  patient  against  the  latter. 

The  ligatures  at  either  side  are  now  tied  together,  but  are  left 
sufficiently  long  to  be  readily  removed ;  a  strip  of  iodoform  gauze, 
two  inches  in  breadth,  and  some  sixteen  inches  in  length,  is 
passed  between  them  so  as  to  fill  loosely  the  space  between  the 
broad  ligaments.  The  end  of  this  is  tied,  and  turned  up  over  the 
pubes,  and  another  tampon  of  sterilized  gauze  supports  this,  and  is 
also  tied,  the  knots  on  both  strings  indicating  the  respective 
tampons.  The  gauze  pack  must  not  be  too  loose  in  the  vagina. 
Some  operators,  in  the  majority  of  cases  in  which  drainage  is  not 
required,  unite  the  peritoneum  across,  or  at  either  side.  Kelly 
unites  it  in  the  centre,  leaving  an  aperture  at  either  side.     The  last 


Figs.  383,  384. — Useful  Blunt-pointed  Broad  Ligament  Scissors. 


step  is  the  passage  of  the  catheter  so  as  to  relieve  the  bladder  and 
afford  proof  that  it  is  uninjured. 

This  description  of  vaginal  hysterectomy  is  to  be  taken  as  specially 
ap^Dlicable  to  the  operation  for  myoma  or  other  tumours  in  which 
the  peri-uterine  structures  are  not  involved,  and  where  there  are  not 
diseased  states  and  tumours  of  the  adnexa,  or  complications  arising 
out  of  adhesions.  When  these  are  present,  the  operation  must 
necessarily  vary  according  to  the  conditions  which  are  met  with  as 
it  proceeds.  The  size  of  the  tumour,  the  difficulty  of  reaching  the 
vessels,  of  bringing  down  the  adnexa,  of  severing  or  detaching 
adhesions,  of  controlling  unexpected  and  obstinate  bleeding,  and,  in 
the  case  of  any  suspicious  malignancy,  of  going  sufficiently  wide  of 
the  uterus  to  remove  infected  tissues  and  glands,  may  each  and  all 


UTERINE  SEOl'LA^MS— MYOMA— iiUltGlCAL    TREATMENT.     523 


compel  the  surgeon  to  alter  his  plan  of  operation.  Thus  the  time 
occupied  will  vary  from  twenty  minutes  to  over  an  hour,  or  even 
longer,  according  to  the  presence  or  absence  of  complications.  The 
internal  strip  of  gauze  is  not  removed  for  eight  days. 

The  operation  is  greatly  facilitated  in  many  cases  by  the  bi-section 
of  the  uterus,  especially  in  cases  in  which  there  are  adhesions  and 
adnexal  complications.  Or  the  size  of  the  uterus  may  be  reduced, 
as  has  already  been  shown,  by  the  exsection  of  triangular  portions 
taken  from  its  wall,  grasping  the  fundus  higher  and  higher  at  each 
side  with  claw  forceps.  In  this  manner  its  bulk  is  reduced,  and  we 
have  obtained  room  to  attack  the  appendages.  In  some  cases  Kelly 
divides  the  uterus  into  quadrants  further  to  facilitate  the  operation.* 
Vaginal  Pan-Hysterectomy  performed  byPryor. — This  operation 
like  Kelly's,  is  specially  adapted  for  cases  of  small  myoma  compli- 
cated with  pelvic  inflammation. 
The  patient  is  placed  in  the 
lithotomy  position,  her  legs 
being  held  flex  by  a  crutch 
on  a  table  capable  of  being 
lowered  to  the  Trendelenbui'g 
position.  Two  semi  -  circular 
incisions,  leaving  a  small  mar- 
gin of  vaginal  mucous  mem- 
brane, are  carried,  preferably 
with  stout  scissors,  posteriorly 
and  anteriorly  so  as  to  sur- 
round the  cervix.  The  pos- 
terior cul-de-sac  is  opened,  and 
the  pelvic  contents  examined. 
Any  obstacles  that  may  be 
found  in  opening  the  cul-de-sac 
are  overcome  by  the  finger  and 

freer  opening  of  the  peritoneum.  An  ectopic  gestation  or  a  retro- 
peritoneal fibroma  may  so  dissect  or  lift  the  peritoneum  as  to 
make  examination  through  the  posterior  pouch  impossible.  It 
must  then  be  made  through  the  anterior  cul-de-sac,  and  it  may 
be  necessary  to  remove  any  myomatous  nodule  that  may  prevent 
the  exploration.  The  bladder  is  next  separated  from  the  uterus, 
any  difficulties  being  overcome  in  the  usual  manner,  as  in  an- 
terior colpotomy.  The  anterior  and  posterior  incisions  are  made 
*  See  Cancer  of  the  Uterus  for  Kelly's  operation  by  quadrisection. 


Fig.  385.— Patient's  Position  in  Pkyok's 
Vaginal  Pan-hystekectomy.     (I^kyor.) 


524 


DISEASES   OF    W02IEN. 


to  spread  laterally  by  means  of  the  finger,  so  that  the  rents  in 
the  peritoneum  are  of  equal  size  with  the  incision  in  the  vagina. 
Hemisection  of  the  uterus  is  now  performed,  the  anterior  wall 
being  divided  to  the  uterine  cornua  by  a  median  incision.  The 
tip  of  the  index  finger,  passed  up  behind  the  uterus,  projects  at 
the  angle  of  the  division  above,  and  a  retracting  groove  director 
is  passed  until  it  projects  in  the  same  position.  Over  this  grooved 
director  the  posterior  wall  of  the  uterus  is  severed  with  a  special 
bistoury,  which  has  its  cutting  edge  along  its  convexity.  The 
operator  now  deals  with  either  half  of  the  bisected  uterus,  the 
left  half  is  usually  first  pulled  out  of  the  vulva,  the  higher 
adhesions  are  manipulated,  and  that  half  of  the  uterus  with  the 
released  adnexa  is  returned  into  the  pelvis.     The  right  half  of  the 


Fig.  386. — Utekus  and  Adnexa  eemoved  by  Petoe's  Vaginal 
Pan^-htsteeectomy.     (Peyoe.) 

uterus,  with  the  adherent  adnexa,  is  liberated  in  the  same  manner. 
Bleeding  is  arrested  during  the  traction  on  either  half.  Yery 
rarely,  says  Pryor,  is  a  quarter  of  "an  hour  needed  to  release  and 
remove  the  tissues  under  a  complete  htemostasis,  the  bleeding  being 
parenchymatous  only.  A  forceps  having  been  applied  to  the 
ovarian  artery,  one  half  of  the  uterus  is  pulled  out  of  the  vagina 
and  the  adnexa  brought  forward.  No  retractors  are  necessary, 
the  forefinger  on  one  side  of  the  broad  ligament,  and  the  middle 
finger  upon  the  other,  while  the  thumb  powerfully  doubles  the 
uterus  and  holds  the  adnexa,  converting  the  entire  mass  into  a 
pedunculated  one  ;  the  forceps  is  applied  from  above  downwards, 
including  the  top  of  the  broad  ligament  and  the  round  ligament. 
The   forceps    has    detachable    handles,    which    are    removed.     The 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     r)25 

tissues  are  cut  to  its  ends,  and  another  forceps  is  applied,  so  as  to 
include  the  uterine  artery,  and  its  handles  are  removed.  This  half 
of  the  uterus  and  the  adnexa  is  cut  away,  and  the  other  half  treated 
in  a  similar  way.  By  means  of  retractors,  anterior,  posterior,  and 
lateral,  the  forceps  and  the  stumps  are  held  back.  Gauze  pads  are 
used  to  take  up  blood  and  discharges,  the  stumps  are  carefully 
inspected,  and  the  dressings  are  now  applied.  The  gauze  pads  are 
removed,  and  the  forceps  with  the  stumps  are  drawn  into  the 
vagina,  and  held  in  this  position,  while  a  piece  of  iodoform  gaiize  is 
adjusted  between  the  forceps  and  vaginal  wall,  and  held  firmly  in 
this  position  by  means  of  a  retractor,  this  being  done  at  both 
sides.  Strips  of  iodoform  gauze  are  now  introduced  between  the 
forceps,  so  as  to  exert  bilateral  pressure  on  the  latter.  Nowhere  is 
a  forceps  allowed  to  touch  a  soft  part.  A  self-retaining  catheter  is 
introduced,  and  the  sphincter  ani  dilated,  so  as  to  lessen  spasm. 
The  forceps  is  removed  in  forty-eight  hours,  and  the  bladder  washed 
out  after  the  catheter  is  removed. 

In  1899  the  author  saw  Schauta  several  times  perform  practically  the  same 
operation,  save  that  in  the  place  of  the  clamp  forceps  he  used  ligatures, 


Fig.  387. — Ehkexfest's  Ligature  Tightexer. 

When  the  first  loop  of  the  knot  is  tightened  over  the  vessel,  the  ends  of  the 
ligature  are  brought  over  the  grooves  at  the  end  of  the  instrument  («),  and 
fixed  ia  the  holder  (b)  by  a  catch.  The  blades  are  pushed  home  to  tlie 
bleeding  point,  and  by  pressure  on  the  handles  are  diverged,  and  the 
ligature  thus  made  tense.  A  moment's  delay  secures  the  tightness  of  this 
loop  of  the  ligature.  Its  ends  are  now  released,  and  the  second  and  third 
knots  are  made. 


attacking  each  side  separately.     He  employs  Ehrenfest's  ligature  tightener 
in  all  cases  in  which  there  is  any  difficulty  in  reaching  the  vessel  (Fig.  387). 

After-management  of  Case. — The  same  treatment  is  adopted  as 
after  laparotomy.  The  patient  is  placed  on  her  back,  the  bladder 
relieved  at  regular  intervals,  and  nourishment  administered  much  as 
in  the  instance  of  the  abdominal  operation,  though  here  we  may 
resort  earlier  to  soft  solid  foods  and  nourishing  liquids.  The  bowels 
are    moved    at    the    latest    on    the    third    day,    preferably    by    an 


526  DISEASES   OF    WOMEN. 

emollient  enema  of  salad  oil  and  thin  strained  gruel.  Should  this 
not  act,  the  patient  may  have  a  few  grains  of  calomel  followed  by  a 
saline  purgative.  When  the  internal  strip  of  gauze  is  removed,  the 
vagina  is  still  kept  loosely  packed  with  a  fresh  tampon  of  the  iodo- 
form gauze  or  chinosol.  I  generally  now  use  moist  chinosol  gauze 
after  the  first  pack  of  iodoform,  thus  avoiding  any  toxic  effects  that 
mioht  follow  from  the  latter.  Should  there  have  been  a  prolonged 
operation,  and  shock  be  threatened  or  present,  a  litre  of  artificial 
serum  should  be  injected.* 

Hsemorrhage. — Secondary  haemorrhage,  attended  by  collapse,  is  the 
most  alarming  of  the  after  consequences  of  vaginal  hysterectomy. 
Should  it  occur,  as  may  be  suspected  from  the  signs  already 
enumerated,  no  time  must  be  lost  in  the  endeavour  to  control  it. 
The  patient  must  be  raised  on  to  the  table.  An  anaesthetic  is 
administered,  and  the  necessary  retractors,  hfemostatic  forceps,  dabs, 
and  sponges,  with  the  dressings  placed  ready  at  hand.  Immediately 
the  patient  is  under  the  anaesthetic,  the  packs  are  removed  from  the 
vagina,  retractors  are  placed  in  position,  and  a  good  light,  if  it  be 
at  night,  thrown  on  to  the  pelvis.  By  gentle  traction  on  the 
ligatures  the  broad  ligaments  may  be  brought  into  view,  and  the 
loose  loop  of  ligature  seen :  the  bleedmg  point  is  immediately 
clamped.  Otherwise,  the  ligament  at  the  side  from  which  the 
bleeding  comes  must  be  drawn  down  with  forceps,  the  bleeding 
point  sought  for,  and  a  pair  of  forcipressure  forceps  made  to 
include  the  bleeding  area,  and  left  on.  Under  any  circumstances, 
should  the  bleeding  persist,  there  must  be  no  delay  or  temporizing, 
but  the  bleeding  tissues  should  be  boldly  clamped  at  either  side. 
These  forceps  should  remain  from  thirty-six  to  forty-eight  hours. 

Injury  to  Ureters. — In  the  chapter  on  ureteral  surgery,  reference 
is  made  to  the  management  of  divided  or  injured  ureters. 

The  Combined  Operation. — In  cert^^in  cases,  either  from  difiiculties 
arising  in  dealing  with  the  adnexa,  or  from  the  size  of  the  tumour, 
and  the  presence  of  multiple  or  pedunculated  myomata,  it  may  be 
necessary  to  complete  the  operation  by  abdominal  cceliotomy.  Here, 
after  the  preliminary  steps  of  the  operation  have  been  taken  by  the 
vagina  (opening  of  the  anterior  cul-de-sac  and  posterior,  separation  of 
the  bladder,  ligature  of  the  uterine  arteries,  and  freeing  the  cervix), 
an  antiseptic  tampon  is  introduced  into  it,  the  hands  are  thoroughly 
sterilized,  and  the  patient  is  placed  in  the  Trendelenburg  position. 
The  abdomen  is  now  opened,  and  the  remainder  of  the  operation  is 
*  See  pages  .5.36,  .5.37. 


UTEIiIXE   NEOPLASMS-MYOMA— 8UMGICAL    TUEATMENT.     a'll 

performed  as  in  pan-hysterectomy,  by  the  abdominal  route.  Such  a 
procedure  is  to  be  avoided  when  possible,  as  submitting  the  woman 
to  a  considerable  prolongation  of  the  operation,  and  the  additional 
risk  involved  in  opening  the  peritoneal  cavity  from  the  abdomen, 
but  such  a  step  is  better  than  to  persist  in  endeavouring,  through 
too  narrow  an  aperture,  to  deliver  a  large  and  probably  adherent 
mass,  or  matted  and  adherent  pyo-cystic  adnexa,  which  with  the 
uterus  resist  delivery  even  after  morcellation.* 

The  steps  of  Doyen's  vaginal  hysterectomy  by  angiotripsy  are 
as  follows  : — 

Having  incised  the  posterior  fornix,  he  opens  the  pouch  of  Douglas, 
and  explores  the  pelvic  cavity.  The  anterior  fornix  is  next  incised, 
and  the  bladder  detached,  the  broad  ligaments  at  either  side  are 
now  secured  by  his  pince,  which  is  applied  for  about  half  a  minute. 

After  a  compression  of  from  forty  to  sixty  seconds  the  inferior  third  of  the 
broad  ligament  may  he  cut  or  torn  in  the  first  stage  of  vaginal  hysterectomy 


Fig.  3S8. — Doyen's  Leveu  Pince.  Fig.  389.— Open  as  Forceps. 

"With  lever  raised  to  exert  pressure.         A  pressure  exerted  with  both  hands 

equal  to  about  100  kilograimnes 
secures  at  the  eud  of  the  forceps 
2000  kilogrammes,  and  1200  in  the 
middle  portion. 

without  any  escape  of  blood.  Towards  the  close  of  the  operation  the 
instrument  is  applied  above  the  adnexa.  Doyen  thinks  it  imprudent, 
however,  to   cut  the  pedicle  without  placing  a  ligature  or  a  small  clamp 

*  Sfanmorc  Bishop.  Brit.  Gijn.  Jour.,  Feb.,  1899. 


Fig.  390. — Uterus  drawn  down — An-      Fig.  391. — Pressure  Forceps  applied 
TERiOR  Cul-de-sac  opened.  (Doyen.)  to  the  Left  Beoad  Ligament  and 

Uterine    Arteries     from    below. 

(Doyen.) 


Fig.  392.— Pressure  Forceps  applied  Fig.  393. — Pressure  to  Upper  Part 

to  the  Right  Broad  I^igament  and  of    Left    Broad    Ligament    and 

Uterine    Arteries    from    below.  .Ovarian     Vessels     from     above. 

(Doyen.)  (Doten.) 


UTERINE  NEOPLASMS— MYOMA— SURGICAL    TREATMENT.     529 

forceps  on  it,  as  the  peritoneal  rent  reascends  into  the  pelvic  cavity  very  high 
when  the  uterus  has  been  detached. 

The  uterus,  having  been  drawn  down,  is  divided  in  two  by 
a  median  or  V-shaped  incision,  the  latter  being  that  of 
selection  for  a  large  tumour.  This  allows  of  the  delivery  of  the 
fundus  and  the   adnexa  ;    the   angiotiibe   is  now  applied  to   each 


x:: 


ViG.  3'Ji. — Deawixg  dowxJthe  Utebus  after  the  Sectiox  has  beex 

COMPLETED — EXPOSURE    OF    FUNDUS.      (DOTEX.) 

broad  ligament,  and  the  complete  separation  of  the  uterus  is  effected. 
The  upper  border  of  the  broad  ligament  is  then  finally  crushed.  A 
silk  thread  is  tied  in  the  groove  formed  by  the  angiotribe,  and,  when 
it  is  removed,  the  ligature  is  gradully  tightened  so  as  to  embrace 

2    M 


530  DISEASES   OF    WOMEN. 

the  entire  broad  ligament.     The  peritoneal  flaps  are  now  brought 
carefully  together,  and  the  vagina  is  tamponed.* 

Doyen's  Clamp  Operation. — Doyen's  operation,  as  performed  with 
his  clamps,  may  be  thus  briefly  described.  The  first  step  of  the 
operation  is  the  same  as  for  posterior  colpotomy,  the  posterior 
vaginal  cul-de-sac  being  incised  from  right  to  left,  and  the  posterior 
vaginal  wall  well  depressed.  The  divergent  blades  of  the  scissors 
are  used  to  open  the  peritoneum.  Through  the  aperture  thus  made 
the  fijigers  are  introduced,  and  the  uterus  and  adnexa  examined. 
This  enables  the  surgeon  to  make  the  final  decision  as  to  the 
advisability  of  removing  the  uterus.  The  incision  of  the  anterior 
vaginal  cul-de-sac  is  next  made  after  the  circular  incision  of  the 
neck  has  been  completed.  The  bladder  is  avoided  by  cutting  with 
the  blunt  point  of  a  curved  scissors  towards  the  uterus,  and,  with 
the  finger  turned  with  the  nail  to  the  uterus,  the  mucous  membrane 
is  raised  and  the  bladder  is  detached  and  got  well  out  of  the  way. 
This  detachment  is  often  facilitated  by  working,  with  a  small 
sponge  or  roll  of  gauze  held  in  a  sponge  forceps,  towards  the  uterine 
surface,  the  pressure  being  directed  away  from  the  bladder.  The 
peritoneal  fold  is  quickly  exposed,  caught  with  a  forceps,  and 
opened  with  the  same  scissors.  By  diverging  the  blades  the  orifice 
is  enlarged,  and  now  a  txiangular-shaped  retractor  is  slipped  between 
the  peritoneum  and  the  body  of  the  uterus.  With  tenacula  the 
uterus  is  successively  caught  in  stages  from  below  upwards,  until 
the  fundus  is  seized  and  turned  over  to  the  vulva.  Should  this 
manoeuvre  be  impossible,  either  through  the  narrowness  of  the  out- 
let, or  the  size  of  the  uterus,  the  organ  is  divided  in  the  middle  line 
as  far  as  the  fundus,  and  drawn  downwards  by  the  tenacula,  fixed 
at  either  side  of  the  lips  of  the  incision.  The  uterus  having  been 
thus  turned  out,  the  adnexa  are  next  brought  down  with  the  aid 
of  an  ovarian  clamp  forceps  at  either  side.  Doyen's  clamps,  large 
(Fig.  395)  and  small  (Fig.  397),  are  now  applied  on  the  broad  ligaments 
from  above  down  at  either  side,  and  the  ligaments  are  cut  between 
the  clamps  and  the  uterus.  Should  any  vessel  bleed,  it  is  caught 
temporarily  in  a  forceps.  A  ligature  may  be  applied  to  any  small 
bleeding  artery.     Doyen's  experience,  up  to  the  commencement  of 

*  Doyen  still  uses  clamps  ta  his  vaginal  pan-hysterectomy  in  the  more 
difficult  cases,  more  especially  in  obese  women  with  a  narrow  vagina,  but  in  all 
other  cases  he  resorts  to  the  angiotribe  and  ligatures.  There  is  no  modification 
of  his  vaginal  pan-hysterectomy  as  performed  in  the  manner  described  in  the 
text.     He  also  uses  the  same  angiotribe. 


UTEliTXE  NE0PLA8M8~MYuMA—SUH(rKAL    TREATMENT.     531 


1898,  led  him  to  prefer,  in  vaginal  hysterectomy,  forcipressure  to 
ligature,  though,  as  he  says,  it  was  from  no  prejudice  that  he  pre- 


FiG.  395.— Duyen's  Lakge  Clamp  FuitcErs. 

ferred  the  former,  as  for  a  long  time  he  used  the  ligature,  and  still 
employs  it  under  certain  indications.     He  applied  the  ligature  when 


Fig.  396. — Application  of  the  Outside  Stuosg  Clamp  to  the  Broad 

Ligament. 


532 


DISEASES   OF   WOMEN. 


the  broad  ligaments  were  very  loose,  and  when  the  adnexa  could  be 
easily  extracted.  Here,  the  ligamentary  pedicles  being  very  thin,  a 
ligature  is  applied  en  masse.  The  thread  is  repassed  a  few  times  by 
trans6sion,  and  retied.  Each  pedicle  is  fixed  on  a  plane  with  the 
vaginal  wound,  and  the  peritoneum  is  closed  by  a  purse  suture,  care 


Fig.  397. — Application  of  the  Two  Olamps,  Strong  and  Slendek,  and 
Section  of  the  Bkoad  Ligaments. 

being  taken  to  pass  the  thread  at  each  side  through  the  peritoneum 
of  the  pedicles  above  their  ligature.  The  anterior  and  posterior 
serous  flaps  being  carefully  adjusted,  a  tampon  is  placed  in  the 
vagina,  and  allowed  to  remain  in  its  position  for  four  days,  after 
which  gentle  douchings  are  commenced.  The  peritoneum  unites 
above  the  ligatures,  and  the  ligamentary  stumps  are  eliminated  by 


UTERINE  NEOPLASMS— MYOMA — WRGICAL    TREATMENT.    533 


the  vagina.  Doyen  prefers  forcipressure  in  all  cases  where  there  is 
difficulty  through  adhesions  or  otherwise,  or  in  removing  the 
adnexa,  as  the  ligature  then  is  difficult  and  does  not  affin-d  as  great 
security.     He  thus  applies  his  clamp  forceps  : — 

Taking  the  left  adnexa  by  i)reference,  these  are  drawn  down,  and 
the  broad  ligament  is  isolated  between  the  left  index  and  middle 
fingers,  which  are  introduced  from  above,  the  one  in  front,  the  other 
behind,  the  ligament.  The  uterine  neck  has  already  been  isolated 
as  much  as  possible,  and  the  fingerSj  reaching  down  by  its  side, 
determine  the  lower  border  of  the  ligament.  A.  large  clamp  forceps 
is  then  introduced  by  the  right  hand,  from  above  down,  embracing 
the  ligament.  Should  any  intestine  or  omentum  protrude,  it  is 
returned  and  supported  by  a  compress,  kept  in  position  by  a  long 
curved  forceps.  The  clamp  is  now  firmly  closed,  after  careful 
inspection  of  the  part  embraced  by  its  blades.  A  second  lighter 
clamp  is  placed  in  front,  and  the  broad  ligament  is  divided  between 
it  and  the  uterus.     The  adnexa  remain  adherent  to  the  uterus. 

Landau's  Operation. — Landau's  operation  by  clamp  alone,  which 
was  described  fully  in  the  last  edition  of  this  work,  has  practically 
become  an  operation  of  the  past. 

In  Landau's  operation,  which  the  autlior  has  seen  him  perform  several 
times,  the  usual  preliminary  steps  of  freeing  the  uterus  and  adnexa  having 
been  taken,  the  latter  were  enucleated  and  any  abscess  debris  evacuated. 
Tlie  broad  ligaments  were  clamped  at  either  side  with  Doyen's  strong  clamp 
forceps,  supported  by  a  slender  pair  of  the  same.  The  number  of  clamps 
applied  to  the  broad  ligament  varied.  When  necessary,  the  uterus  was 
divided  with  the  scissors,  from  the  anterior  down  to  the  posterior  wall. 
Thus  greater  power  was  obtained  over  either  half  of  the  fundus.  Hajmostasis 
was  secured  by  forceps,  and  the  vagina  was  dressed  with  iodoform  gauze 
tampons  which  were  not  removed  for  forty-eight  hours.  Sometimes  he 
practised  complete  morcellement  of  the  affected  uterus.  After  section  of  the 
uterus,  the  uterine  segments  were  drawn  down  by  strong  claw  forceps,  and 
thus  hfemorrhage  was  restrained.  The  broad  ligaments  were  secured,  and  at 
times  the  uterus  was  brought  away  piece  by  piece  with  Landau's  curved 
knife  or  special  scissors.  Such  morcellation  was  absolutely  necessary  in  some 
cases  of  fibroid,  malignant  disease,  and  extensive  adhesions.  Thus  in 
Landau's  operation  no  ligatures  were  used  from  first  to  last. 


CHAPTER   XXIX. 

SURGICAL   TREATMENT    OP    UTERINE 
MYOMA  (continued). 

Hysterectomy — Post-operative  Treatment. 

When  the  operation  is  completed  (see  chapter  on  asepsis)  the 
patient  is  placed  in  bed  with  a  pillow  under  the  knees  and  hot 
bottles  to  the  feet. 

A  word  of  caution  regarding  hot-water  pillows,  jars,  and  bottles  is  necessary. 
I  have  known  of  most  serious  consequences  arising,  both  on  the  operating- 
table  and  after  a  patient  has  been  placed  in  bed  in  a  semi-conscious  state, 
from  the  pillow,  jar,  or  bottle  having  been  filled  with  water  at  too  high  a 
temperature,  the  mischief  done  not  being  discovered  until  too  late,  and 
extensive  burns  with,  in  some  instances,  deep  sloughs  following.  To  avoid 
this  is  part  of  the  nurse's  duty,  but  any  accident  that  happens  during  or  after 
an  operation  is  apt,  no  matter  how  unjustly,  to  be  laid  at  the  surgeon's  door. 

The  administration  of  a  stimulant  by  the  rectum  may  be  neces- 
sary, or  a  subcutaneous  injection  of  strychnine. 

Shock. — Among  the  chief  factors  which  directly  cause  shock  after 
an  abdominal  operation  is  its  prolongation  beyond  the  capacity  of 
the  patient's  vital  resistance.  The  evil  influence,  however,  of  the 
length  of  an  operation  in  causing  shock  will  largely  depend  upon 
the  unavoidable  accidents  which  have  occurred  during  its  perform- 
ance, as  haemorrhage,  exposure  and  handling  of  the  bowel,  much 
dragging  about  of  the  parts  operated  upon,  prolonged  anaesthesia, 
also  inadequate  precautions  for  maintaining  the  body  temperature. 

In  refen'ing  to  death  after  abdominal  coeliotomy,  Smyly  recapitulates  the 
predisposing  causes  of  shock.*  Amongst  these  he  dwells  specially  on  the 
influence  of  debilitating  diseases,  such  as  cancer,  bleeding  myomata,  and 
granular  kidney,  but  more  particularly,  he  says,  is  failure  of  the  heart  likely 
to  follow  in  the  case  of  those  women  who  have  what  is  commonly  called 
weak  hearts,  with  rapid  and  weak  action  :    In  such  cases  there  is  a  tendency 

*  Brit.  Gyn.  Jour.,  May,  1899. 


SURGICAL    TREATMENT   OF    UTERINE   MYoMA.  r)35 

to  general  stasis  of  tlic  circulation,  as  also  of  the  lymph-currents  in  the 
peritoneal  cavity.  Asepsis,  a  sound  heart  with  undisturbed  circulation,  and  a 
normally  acting  peritoneum,  are  the  three  most  important  factors  in  resisting 
the  predisposition  to  shock. 

A  prolonged  operation,  much  exposure  and  handling  of  the 
bowels,  involving  derangements  of  the  functions  of  the  peritoneum, 
are  universally  acknowledged  to  be  specially  dangerous  in  women 
in  whom  we  are  apprehensive  of  the  occurrence  of  shock. 

Sanger,  to  obviate  the  influence  of  a  dry  peritoneum,  advocates  the  use  of 
warm,  moist  protecting  compresses,  squeezed  nearly  dry,  for  covering  the  bowel 
and  exposed  intestine  ;  others,  as  Zweifel,  and  Smylj^  himself,  prefer  dry  steri- 
lized gauze.     Those  I  use  are  wiimg  out  of  weak  formalin  solution. 

Signs  and  Symptoms. — Should  alarming  shock  threaten  during 
an  operation,  it  is  indicated  by  the  extreme  pallor  of  the  face  and 
coldness  of  the  body,  while,  at  the  same  time,  the  pulse  becomes 
more  rapid  and  indistinct.  The  respiratory  movements  are  weaker, 
and  become  almost  imperceptible.  When  such  conditions  occur, 
they  are  indications  for  increased  care  and  precautions  anticipative 
of  post-operative  shock.  Anxiety  is  further  added  to  should  there 
be  difficulty  in  rousing  the  patient  from  the  anaesthesia.  Here  the 
administration  (submammary)  of  artificial  serum  should  be  com- 
menced at  once  and  a  subcutaneous  injection  of  ^th  gr.  of  strych- 
nine given.  The  peritoneal  cavity  may  also  be  flushed  out  with  a 
warm  sterilized  saline  solution.  When,  subsequent  to  the  operation, 
such  conditions  are  followed  by  a  weak,  compressible,  and  very 
rapid  pulse,  sustained  coldness  of  the  body,  Avith  perspiration  and 
pallor,  while  the  whole  appearance  of  the  patient  is  such  as  to 
indicate  impending  death,  most  active  measures  must  be  taken  to 
counteract  these  conditions.  Before  she  leaves  the  table  strychnine 
should  be  given  hypodermically  with  a  drachm  of  sulphuric  ether, 
and  a  brandy  enema  administered.  The  best  enema  is  one  of  two 
ounces  of  brandy  with  six  ounces  of  warm  beef-tea.  The  strych- 
nine is  repeated  in  smaller  doses  at  intervals,  varied  according  to  the 
degree  of  shock,  as  also  are  the  brandy  enemata.  Every  possible 
means  is  taken  to  maintain  the  body  temperature  of  the  patient  by 
hot- water  tins  and  bottles.  The  foot  of  the  bed  is  elevated,  and 
artificial  serum  is  periodically  injected.  A  persistent  subnormal 
temperature  and  the  absence  of  the  evidences  of  reaction  in  pulse, 
temperatui'e,  skin,  and  consciousness  are  the  most  unfavoui^able 
signs.  From  such  a  condition  of  shock,  attended  by  transient 
delirium,  the  patient  may  pass  through  the  stage  of  reaction  into 


536  DISEASES   OF   WOMEN. 


a  state  of  traumatic  delirium,  the  degree  of  intensity  of  which 
varies,  and  which  may  be  succeeded  by  the  subsidence  of  the 
symptoms  of  shock,  a  gradual  lessening  of  the  pulse,  a  rise  of 
temperature,  restoration  of  the  general  warmth  of  the  body,  better 
appearance  of  the  patient  generally,  a  return  to  consciousness,  and 
the  cessation  of  delirium.  In  such  cases  it  is  well  to  proceed 
cautiously  in  the  administration  of  fluid  by  the  mouth.  The 
stomach  does  not,  under  such  conditions,  absorb  well,  and  it  is 
better  to  trust  to  the  administration  of  nutriment  and  stimulant  by 
the  rectum.  The  duration  of  the  treatment  will  depend  upon  the 
time  over  which  the  symptoms  of  shock  are  prolonged,  and  of 
necessity  will  be  modified  accordingly. 

The  TJse  of  Artificial  Serum. — Before  injecting  artificial  serum  into  the 
cellular  tissue  of  the  mamma,  the  skin  around  and  under  the  gland  is  well 
washed  with  antiseptic  soap,  some  perchloride  and  alcohol  solution  is  rubbed 
over  it,  and  then  the  whole  part  washed  over  with  ether.  The  sterilized 
needle  (Fig.  89)  is  inserted  for  about  two  inches,  and  when  the  fluid 
begins  to  distend  the  part,  absorption  is  accelerated  by  manipulating  the 
gland.  The  serum  is  allowed  to  flow  until  the  requisite  quantity,  from  half  a 
litre  to  a  litre,  is  injected.  The  small  wound  left  is  closed  with  collodium. 
The  most  convenient  solution  is  that  of  distilled  water  with  chloride  of 
sodium,  sterilized  by  previous  boiling  for  twenty  minutes.  It  should  be  of 
the  temperature  of  the  body  when  injected,  and  therefore  ought  to  be  of  at 
east  100°  when  placed  in  the  receiver  for  use  at  the  time  of  injection.  Ten 
ounces  may  be  introduced  in  a  few  minutes,  and  the  quantity  may  be  increased 
to  over  two  litres  without  causing  any  symptoms  of  intolerance.  This, 
however,  should  be  the  maximum  at  one  sitting,  and  four  htres  within  the 
twenty-four  hours  the  outside  limit  in  the  gi-eat  majority  of  cases  in  which  the 
injection  is  indicated.  The  artificial  serum  may  also  be  administered  by  the 
rectum. 

Food. — Food  is  limited  to  the  administration  of  small  quantities 
of  hot  water,  and  possibly  some  barley-water,  for  the  first  twenty- 
four  to  thirty-six  hours.  Occasionally  a  little  freshly  drawn  tea  is 
allowed.  As  a  rule,  not  until  after  thirty-six  hours  is  it  well  to 
aive  milk,  and  then  it  is  diluted. 

If  there  be  vomiting,  nourishment  is  given  by  the  rectum  after  it 
has  been  cleansed  with  a  boric  acid  injection.  Varying  quantities 
of  brandy,  as  indicated  by  the  strength,  with  milk  and  yolk  of  egg 
or  beef-tea,  are  administered.  It  is  better  to  abstain  in  doubtful 
cases  from  concentrated  meat  essences  until  forty-eight  hours  at 
least  have  passed,  but  this  must  depend  upon  the  condition  of  the ' 
patient. 

Brand's,  Valentine's,  or  Wyeth's  are  those  most  frequently  used. 


SURGICAL    TREATMENT  OF   UTERINE  MYOMA.  537 


Carnick's  beef  peptonoids,  in  the  form  of  suppositories,  are  useful. 
Of  late  years,  operators  are  more  inclined  to  feed  patients  sooner 
and  more  generously  after  operation.  Experience,  however,  does 
not  lead  me  to  recommend  such  early  feeding.  The  nature  and 
amount  of  the  nutriment  given  must  altogether  depend  upon  the 
condition  and  post-operative  complications  of  the  case.  These 
must  guide  us  as  to  the  relative  amounts  to  be  given  by  the  mouth 
or  rectum,  and  the  quantity  of  stimulating  and  supporting  food 
that  is  called  for.  It  is  far  safer  to  feel  one's  way,  and  to  wait  for 
the  indications  for  solid  food  by  the  progress  made,  the  quietness 
of  the  stomach,  and  absence  of  sickness.  The  pulse,  temperature, 
and  freedom  from  abdominal  distress  are  our  main  indications. 

Morphia. — It  is  best  to  abstain  from  the  use  of  morphia,  unless  it 
be  absolutely  called  for.  It  may  well  be  combined  with  atropine 
in  subcutaneous  injection.  If,  however,  the  choice  has  to  be  made, 
as  between  sleeplessness  and  exhaustion  from  pain  or  nervous  rest- 
lessness and  irritability,  and  the  ill  effects  of  the  morphia  in  inter- 
fering with  digestion  and  intestinal  action,  the  resort  to  morphia 
must  be  regarded  as  the  lesser  evil. 

Tympanitic  Distension. — Tympanitic  distension  and  flatus  are 
best  met  by  the  passage  of  a  long  rectal  tube,  which  may  be  worn 
for  a  short  time  and  passed  three  or  four  times  in  the  day.  This 
may  be  done  with  the  patient  in  the  knee-elbow  position,  as  advised 
by  Swatman.  The  light  application  of  a  Paquelin's  or  electric 
cautery  to  the  abdominal  wall  in  gentle  touches,  just  sufficient  to 
cause  red  lines,  is  an  admirable  method  of  treating  tympany." 

Management  of  the  Bowel.— Much  has  been  written  on  the 
management  of  the  bowel.  It  must  be  remembered  that  if  a 
patient  have  been  properly  prepared  for  operation,  and  the  bowel 
thoroughly  emptied  beforehand,  there  ought  not  to  be  that  necessity 
for  early  administration  of  purgatives  advocated  by  some  surgeons. 
Their  use  must  depend  upon  the  symptoms  of  the  particular  case. 
If  everything  be  going  on  favourably  we  may  safely  wait  until  the 
third  morning,  and  then  commence  with  gr.  i.  doses  (in  tablets)  of 
calomel  every  hour  until  five  grains  are  given.  At  the  end  of  this 
time  a  full  emollient  enema  is  administered.  Turpentine  is  a  most 
valuable  drug  in  cases  of  tympanitic  distension,  and  may  be  used 
in  an  injection  of  an  emulsion  of  yolk  of  egg  with  dill  or  carraway 
water.  The  treatment  advocated  by  Baldy,  of  giving  drachm  doses 
of  sulphate  of  magnesia  every  half-hour  for  five  or  sLx  doses,  is 
*  See  also  chapter  on  the  Eectum. 


538  DISEASES   OF   WOMEN. 

generally  effectual  if  the  magnesia  be  tolerated ;  or  another  good  plan, 
which  I  occasionally  follow,  is  to  give  an  enema  no  later  than  the 
morning  following  the  operation.  It  generally  operates.  Two  useful 
forms,  if  there  be  delay  in  movement  or  some  abdominal  distension, 
are  —  (1)  Turpentine,  ^iv. ;  tinct.  assafcetida,  ^iv. ;  ol  ricini,  5VJ. ; 
ol  olivse,  '^iv. ;  made  into  an  emulsion  with  the  yolk  of  egg,  and  added 
to  a  pint  or  more  of  thin  starch  water.  (2)  We  may  add  to  this  ^j 
sulphate  of  magnesia.  An  enema  of  alum  has  been  strongly  recom- 
mended as  an  efficient  purgative  in  obstinate  post-operative  closure 
of  the  bowel.  A  seidlitz  powder  is  another  simple,  and  with  some 
an  efficacious,  means  of  opening  the  bowel  for  the  first  time.  The 
rectal  tube  is  worn  for  a  few  hours  at  a  time  to  permit  the  escape  of 
flatus. 

Use  of  the  Catheter. — With  regard  to  the  bladder,  the  water  is 
drawn  off  every  six  hours  with  glass  catheters,  treated  in  the  manner 
I  have  referred  to  in  the  chapter  on  asepsis,  and  the  surgeon  should 
see  specimens  of  the  urine  for  several  days,  so  as  to  judge  of  its 
condition  and  the  state  of  the  bladder. 

Temperature  of  Room  and  Quiet. — The  temperature  and  ven- 
tilation of  the  room  has  to  be  carefully  supervised,  and  neither 
relatives  nor  friends  should  see  the  patient  for  a  few  days  after  the 
operation. 

Dressing  of  Abdominal  Wound. — If  it  be  thought  well  to  look 
at  the  abdominal  wound,  the  hands  of  the  surgeon  and  nurse  should 
be  prepared,  and  towels  wet  with  carbolized  water  should  be  ready 
at  hand  with  all  necessary  dressings  on  a  tray.  The  bandages 
having  been  removed,  the  deeper  dressings  are  covered  with  the 
warm  towel,  and  this  is  allowed  to  remain  on  for  a  few  minutes. 
Then  the  dressings  are  carefully  raised,  and  the  wound  inspected. 
Should  these  be  soiled,  they  are  quickly  replaced  by  fresh  sterilized 
ones,  and  the  bandages  re-applied. 

In  the  great  majority  of  cases  it  is  not  necessary  to  disturb  the 
actual  dressing  until  the  fifth  or  sixth  day,  if  it  be  properly  kept 
in  situ,  and  there  be  no  soiling ;  but  the  abdominal  swathe  ought 
to  be  changed  from  day  to  day,  so  as  to  give  comfort  to  the  patient. 

The  appearance  of  any  serum  oozing  up  through  the  lips  of  the  wound, 
and  redness  or  pouting  of  the  suture  apertures,  are  indications  that  the  wound 
has  to  be  watched.  It  is  well  to  make  light  pressure  on  the  sides  of  the 
wound  so  as  to  judge  if  any  secretion  be  imprisoned,  whether  of  serum  or 
pus.  Should  this  be  so,  a  few  of  the  loops  of  the  suture  at  its  lower  end' 
must  be  cut,  and  pressure  made  so  as  to  evacuate  the  secretion ;  then  a  small 
drain  of  iodoform  gauze  soaked  in  formalin  should  be  passed  in,  and  the  dressing 


SURGICAL    THE  ATM  EXT   OF   UTERINE   MYOMA.  SSlJ 


made  twice  daily.  If  a  deep  sinus  be  found  this  must  be  cleansed  out  with  a 
sinus  forceps,  and  some  moist  formalin  gauze  (1  in  1000)  passed  to  the 
bottom  of  the  track  a  few  times  until  it  comes  out  quite  clean.  Or  a  sinus 
syringe  may  be  used  to  pass  down  the  canal  and  gently  wash  it  out. 

Position  of  Patient  in  Bed. — As  regards  the  position  of  the 
patient,  the  dorsjil  one  is  the  best,  as  a  rule,  for  the  fii-st  few  days, 
and  even  longer  than  this  in  vaginal  hysterectomy.  It  is  both  on 
clinical  and  anatomical  grounds  the  safest,  but  she  may  be  permitted 
to  turn  on  her  side  and  vary  the  posture  after  this.  This  rule  as 
to  position  may,,  however,  be  relaxed,  according  to  the  feelings  of 
the  patient  and  other  considerations.  There  is  nothing  to  be  gained 
by  enforcing  the  dorsal  position  to  her  discomfort,  as  this  only 
contributes  to  restlessness. 

From  the  experiments  of  Muscatello,  who  showed  that  leucocytes, 
wandering  cells  and  granules,  were  carried  through  the  lymph 
spaces  from  the  peritoneal  cavity  into  the  blood,  a  current  existing 
with  a  direction  towards  the  diaphragm,  reaching  the  lymph  glands 
of  the  thorax,  the  liver,  and  spleen,  these  currents  being  influenced 
by  gravity,  the  pumping  action  of  the  diaphragm,  and  the  vermicu- 
lar action  of  the  intestine,  Bishop  urges  that  this  action  should 
be  excited  as  soon  after  operation  as  possible,  so  that  we  may  have 
its  aid  in  carrying  stray  micro-organisms  away  from  points  where 
they  are  likely  to  develop  into  the  lymphatics  and  glands.  Thus 
early  action  of  the  bowel  and  the  inclined  position  of  the  bed  are 
two  important  points  in  the  post-operative  management  of  hyste- 
rectomy. Heywood  Smith  first  advocated  this  elevation  of  the 
feet  by  the  placing  of  blocks  of  wood  under  the  legs  of  the  foot 
of  the  bed. 

Thirst  and  Vomiting. — Thirst,  if  not  excessive,  is  met  by  repeated 
sips  of  water  and  small  quantities  of  iced  lemonade,  with  a  few- 
drops  of  dilute  phosphoric  acid  added.  Ice  by  itself  is  better 
avoided.  If  the  thirst  should  prove  excessive,  the  proper  plan  to 
adopt  is  to  pass  a  large  saline  enema  into  the  rectum. 

Clark  and  Howard  Kelly  administer  the  saline  under  an  ana3sthetic.  If  it 
be  given  as  a  preventive,  it  must  be  used  at  the  close  of  tlie  operation  while 
the  i>atient  is  still  on  the  table.  Not  onlv  is  thirst  alle\aated,  but  vesical 
irritability  is  prevented,  and  the  specific  gravit}^  of  the  urine  is  lowered.  The 
amount  of  fluid  given  by  the  mouth  must,  of  course,  be  increased.  Greig 
Smith,  remarking  on  the  vomiting  of  peritonitis,  says  it  '  is  not  of  a  sort  to  be 
controlled  by  medicine ;  indeed,  it  is  doubtful  if  it  be  desirable  to  check  it.' 
The  vomiting,  as  he  points  out,  frequently  relieves  the  distended  bowel  of  its 
liquid  and  gns.     He  found  'the  administration  of  as  ranch  fluid  as  the  patient 


540  DISEASES   OF   WOMEN. 

will  drink — soda-water,  weak  tea,  or  simple  warm  water — is  followed  by  the 
evacuation  of  bilious  fluid  and  gas,  making  her  comfortable  in  a  few  hours.' 

More  harm  than  good  is  generallj'  done  by  drugs  given  to  check  vomiting, 
and  the  safest  course  to  adopt  when  sickness  begins  and  does  not  yield  to 
ordinary  remedies,  is  to  resort  at  once  to  rectal  feeding,  and  to  employ  lavage 
of  the  stomach,  especially  if  the  vomited  matter  be  dark  or  black  in  colour. 
I  find,  in  mild  cases,  an  effervescing  mixture,  made  by  placing  a  powder  of 
carbonate  of  soda  with  carbonate  of  bismuth  in  a  mixture  of  citric  acid  or 
lemon  juice,  with  the  liquor  bismuthi,  is  often  effectual  in  checking  the  nausea. 

R.     Bismuthi  carb.,  5iss. 
Sodii  carb.,  jiiss. 
Liq.  bismuthi  (Schacht),  5iv. 
Syrupi  Simp,  3iv. 
Aquam  ad  5viii.  5iv. 
,^ss.  to  be  taken  with  jii.  of  the  acid  mixture.     The  latter  is  either  pure 
lemon  juice  or  a  mixture  of  .32  gr.  to  the  ounce  of  citric  acid. 

Iced  champagne  given  in  small  quantities  frequently  is  of  service,  and  a 
sinapism  may  be  laid  over  the  epigastrium.  A  mixture  containing  weak 
lemon  juice  and  dilute  phosphorous  acid  given  occasionally  in  sips  has  also  a 
good  effect  in  allaying  thirst.* 

Post-operative  Complications  :  Peritonitis — Different  forms  of : 
Traumatic  ;  Septic.  Obstruction  of  Bowel ;  Ileus. — In  the  various 
forms  of  peritonitis,  whether  of  the  ordinary  traumatic  or  plastic 
kind,  or  that  due  to  septic  infection,  with  its  consequent  septicseraia, 
we  have  to  deal  with  the  most  anxious  and  alarming  post-operative 
conditions  that  follow  upon  cceliotomy.  There  is  a  train  of 
symptoms  which,  when  they  occur,  leave  little  doubt  as  to  the 
dangerous  complication  we  have  to  fear  and  treat.  These  are : 
some  swelling  in  the  epigastric  region  attended  by  pain ;  the  pulse 
becomes  more  rapid,  and  is  altered  in  character,  feeling  less  com- 
pressible and  gradually  becoming  harder ;  the  temperature  rises,  at 
first  a  degree  or  two,  and  then  becomes  more  elevated,  with  some 
fluctuations ;  the  patient  grows  restless,  the  facial  expression  is 
somewhat  anxious,  there  is  pallor  of  the  countenance.  These 
symptoms  may  take  some  time  to  develop,  or  they  may  progress 
with  alarming  rapidity.  According  to  their  relative  degree  of 
severity  we  have  an  indication  of  the  danger  to  which  the  patient 
is  exposed. 

In  not  a  few  cases  the  pulse  and  temperature  ranges  are  very  erratic. 
Though  the  case  progresses  favourably  otherwise,  the  temperature,  or  pulse, 
or  both,  do  not  fall  to  normal.      These   cases  keep  the  surgeon  anxious,' 

*  Cachets  of  Benzo-naphthol  in  many  cases  of  sickness  with  foul  breath  are 
very  useful— .5  to  10-grain  doses. 


SURGICAL    TREATMENT  OF   UTERINE   MYOMA. 


541 


and  lightly  so.  As  between  bowel,  temperature,  and  pulse,  I  am  inclined  to 
place  most  importance  in  their  relative  order  to  bowel,  pulse  rate,  and 
temperature. 

As  simple  peritonitis  is  the  least  dangerous  form,  and  frequently 
with  treatment  subsides,  the  pain  lessening,  the  temperature  reced- 
ing, and  the  pulse  softening  and  decreasing  in  rapidity,  it  becomes 
a  matter  of  great  importance  to  note  those   signs  and   symptoms 


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Fig.  H98. — Temperature  Chart  of  Case  on  whom  Supra- vaginal  Hysterec- 
tomy WAS  performed  for  a  Large  Myoma  fixed  in  the  Pelvic  Floor 
BY  Adhesions. 

The  pulse  remained  exceptionally  high  throughout  convalescence,  and  the  tem- 
perature was  also  very  high  at  times,  the  pulse  reaching  to  170  and  the 
temperature  to  102'8  on  the  fourteenth  day  after  operation.  Nevertheless 
the  patient  made  an  excellent  and  permanent  recovery  and  there  were  no 
complications. 

which    assist    us    in     differentiating   the    causes    of     post-operative 
peritonitis. 

If  there  be  localized  peritonitis  setting  in  after  the  operation, 
and  occlusion  or  strangulation  of  a  distant  part  of  the  intestine  be 
the  consequence,  the  most  important  signs  are  the  presence  of 
meteorismus  of  the  strangled  loop  of  intestine  which  is  recognizable 
to  the  view,  and  can  be  detined  by  palpation  or  percussion  (Wahl.), 


542  DISEASES   OF    WOMEN. 

together  with  peristalsis  of  the  intestine,  limited  to  the  obstructed 
portion  of  the  bowel  (Schlange). 

Such  localized  peritonitis  is  generally  of  the  traumatic  character, 
and  this  form  is  not,  as  a  rule,  attended  by  the  graver  symptoms 
found  in  true  obstruction  or  iia  septic  peritonitis.  Still,  it  must  be 
remembered  that  such  traumatic  inflammation  and  exudation  are 
frequently  the  forerunners  of  graver  states,  and  may  in  themselves 
lead  to  strangulation  of  the  bowel  and  complicate  ileus.  We  have, 
however,  early  warning  in  the  rapidity  with  which  the  symptoms 
follow  the  operation,  the  severity  of  the  pain,  the  comparatively 
slight  elevation  of  temperature,  the  general  aspect  of  the  patient 
indicating  uo  profound  systemic  change,  more  especially  in  the 
absence  of  excessive  vomiting  and  extreme  rapidity  of  pulse.  If 
sepsis  be  the  cause  of  the  peritonitis,  and  we  have  to  face  that 
most  dreaded  of  all  operative  states,  septic  peritonitis,  the  train  of 
symptoms  is  generally  unmistakable.  In  this  case  all  the  usual 
evidences  of  peritonitis  are  accentuated  ;  though  it  does  not  set  in 
so  early  as  in  the  case  of  the  simpler  form,  there  is  an  alarmingly 
rapid  development  of  symptoms,  pointing  generally  to  a  fatal  issue.* 
We  may  summarize  these  thus :  great  increase  of  anxiety  on  the 
part  of  the  patient ;  pain,  at  first  extreme,  possibly  not  continuous, 
and  becoming  less  as  death  approaches ;  uncontrollable  vomiting, 
at  first  of  the  contents  of  the  stomach,  then  of  a  greenish  or  dirty- 
coloured  fluid,  finally  dark-coloured  or  almost  black  •  considerable 
tympanitic  distension,  though  cases  do  occur  in  which  the  intensity 
of  the  poison  appears  to  be  so  great  that  neither  is  there  pain  nor 
any  considerable  tympanites. 

The  condition  of  the  mind  varies.  In  some  it  remains  quite  clear, 
and  there  is  little  or  no  delirium.  In  others,  it  is  constantly  present. 
The  temperature  reaches  to  104°  or  105°  Fahr.  ;  and  the  pulse, 
becoming  more  rapid,  ranges  from  130  to  140  or  more.  This  is 
characteristic  septic  peritonitis. 

If  there  be  septic  intoxication  as  a  consequence  of  the  perito- 
nitis, the  patient  may  suffer  from  pysemic  conditions,  as  abscesses, 
pleurisy,  pleuro-pneumonia,  pericarditis,  and  endocarditis. 

Ileus. — Should  we  have  to  deal  with  a  strangulation  and  result- 
ing ileus  due  to  any  cause,  we  are  assisted  in  our  diagnosis  by  the 
more  paroxysmal  nature  of  the  pains  and  the  usual  signs  and 
symptoms  of  ileus,  such  as  the  peristaltic  contractions  of  the  bowel, 
the  tendency  to  collapse  which  follows  these,  and  the  difficulty  or 
*  See  page  514  re  hematemesis  after  hysterectomy. 


SURGICAL    TliEATMENT   OF    UTERINE    MYOMA.  54: 


impossibility  of  obtaining  a  motion.  Such  griping  or  colicky  pains 
are  quickly  followed  by  nausea,  vomiting,  and  tympanites,  and  if 
there  be  no  relief  the  patient  dies  with  all  the  usual  symptoms  of 
strangulation,  with  possible  gangrene  of  the  intestine  or  omentum. 
Should  the  ileus  remain  unrelieved  for  any  time,  the  symptoms 
merging  into  those  of  general  peritonitis,  it  is  most  difficult  to  dis- 
tinguish between  the  two  aflections. 

Intestinal  Obstruction  and  Ileus. — Uhlmau  noticed  iu  Zweifel's  clinic 
that  adhesions  were  never  found  between  coils  of  intestine,  save  in  parts 
whicli  had  been  denuded  of  peritoneum.  Paroxysmal  pain,  arrest  of  the 
peristaltic  action  of  the  intestine,  cold  perspiration,  absence  of  flatulent 
expulsion  by  the  bowel,  are  also  some  of  the  most  pronounced  of  the  early 
symptoms  of  ileus.  Srayly  advocates  early  reopening  of  the  abdomen 
should  the  ordinary  means  of  treatment  of  the  obstructed  bowel  not  succeed. 

Martin  of  Buraingham  thus  tabulates  the  causes  of  intestinal  obstruction : — 

(1)  Inclusion  of  intestine  between  the  lips  of  the  abdominal  wound. 

(2)  Transfixion  of  intestine  while  sutmnng  the  wound. 

(3)  Constriction  of  the  rectum  by  utero-sacral  folds,  when  there  is  much 
tension  on  the  stump  after  hysterectomy. 

(4)  Annular  constriction  of  the  rectum  by  a  hfematocele. 

(5)  Paresis  of  the  bowel  from  atony  and  flatulent  distension  in  a  feeble 
woman  after  removal  of  a  large  ovarian  tumour. 

(6)  Paresis  due  to  peritonitis. 

(7)  Secondary  obstruction — (a)  due  to  adhesion  of  a  coil  of  intestine  to  a 
raw  surface,  such  as  the  cut  surface  of  a  pedicle,  left  at  the  close  of  operation ; 
(6)  due  to  matting  of  intestines  after  peritonitis. 

Prophylaxis. — The  surgeon  is  hopeless  who  does  not  realize  that 
the  causes  of  any  form  of  peritonitis  following  operation  are 
probably,  though  not  necessarily,  to  be  found  in  some  want  of  aseptic 
precaution  or  operative  defect  during  its  performance,  at  any  rate 
in  a  large  proportion  of  cases. 

It  is  well  to  epitomize  these  prophylactic  points  in  the  performance  of  an 
operation,  the  observance  of  which  wiU  considerably  minimize  the  consequent 
risks  of  peritonitis. 

(a)  The  closest  attention  to  aseptic  details. 

(6)  Careful  protection  of  the  bowel,  with  as  little  injury  or  handling  of  it 
as  possible. 

(c)  Cautious  freeing  of  intestinal  adhesions,  whether  inter-intestinal  or 
intra-pelvic. 

{d)  Avoidance  of  strangulation  of  the  omentum  by  sutures  or  ligatures, 
and  careful  replacement  of  it  before  closing  the  abdominal  wound. 

(e)  Perfect  adaptation  of  the  peritoneal  edges,  and  the  covering  by  it  of  all 
denuded  suifaces. 

(/)  Effective  drainage  in  suitable  cases. 

{g)  Avoidance   of  the   necessity   for   prolonged   autesthesia   by   as   great 


544  DISEASES   OF    WOMEN. 


rapidity  of  operation  as  is  consistent  with  the  complete  arrest  of  haemorrhage 
and  attention  to  the  foregoing  details. 

Such  care  will  in  the  majority  of  cases  obviate  the  necessity  for 
a  drainage  tube,  in  itself  a  potent  source  of  peritoneal  complications. 

Sepsis  from  Approaching  Death. — Fritsch  lays  special  stress  on  those  cases 
in  which  the  physiological  iunctions  of  the  peritoneum  are  interfered  with, 
and  attriLiites  the  early  onset  of  dangerous  symptoms  which  occur  without 
rise  of  temperature  before  the  second  day  to  this  cause.  The  early  symptoms 
of  tympanites,  dry  tongue,  and  rapid  circulation  are  characteristic  of  this  class 
of  case.  The  temperature  does  not  rise  until  the  second  day,  and  the  patient 
does  not  die  because  she  is  septic,  but  she  iecomes  septic  because  she  is  dying. 

Reopening  of  the  Abdomen. 

It  must  ever  be  a  matter  for  the  gravest  consideration  whether  or  not  the 
abdomen  should  be  opened  when  symptoms  of  peritonitis  or  what  appear  to 
be  those  of  septic  peritonitis  or  ileus  are  present. 

Much  will  depend  upon  the  nature  of  the  operation ;  the  conditions,  found 
during  its  performance ;  the  presence  of  secretions,  whether  of  serum  or  pus ; 
and  the  probability  of  post-operative  adhesions  having  formed.  Secondly,  on 
the  determination  as  to  the  nature  of  the  peritonitis,  and  the  view  that 
obstruction,  if  present,  is  due  to  strangidation.  Thirdly,  where  signs 
generally  point  to  the  presence  of  ileus.  Fourthly,  the  occurrence  of  intra- 
peritoneal htemorrhage,  whether  sudden  or  slow.  Here  the  usual  evidences 
of  internal  haemorrhage,  in  pallor,  the  thin  and  compressible  pulse,  genei'al 
restlessness  and  distress,  are  sufficiently  indicative  of  this  accident,  leaving 
the  surgeon  no  choice  but  to  operate  at  once. 

When  peritoneal  complications  declare  themselves,  the  first  essential  point 
is  to  secure  free  action  of  the  bowel.  I  prefer  small  doses  of  calomel  given 
every  hour  for  four  or  five  doses.  At  the  end  of  this  time  a  saline  purgative 
is  administered,  unless  we  are  uncertain  of  its  tolerance  by  the  stomach, 
when  an  enema  is  substituted.  Here,  again,  where  there  is  nausea  or 
tendency  to  vomiting,  we  had  better  solely  rely  on  rectal  feeding. 

Ice  to  Abdomen. — Perhaps  the  most  effectual  of  all  means  of  checking  peri- 
tonitis is  the  application  of  a  hght  ice  poultice  over  the  abdomen.  The  ice 
is  finely  pounded  and  placed  between  two  layers  of  flannel  and  covered  with 
protective ;  or  an  abdominal  ice  cap  is  laid  on  with  a  layer  of  flannel  underneath. 

Examination  of  the  Wound,  and  Exploration  of  the  Abdomen 
and  Pelvis. 

Should  the  wound  show  signs  of  inflammation  and  suppuration, 
it  must  be  immediately  re-opened,  thoroughly  cleansed  with  weak 
formalin  solution,  and  drainage  resorted  to.  •  It  may  be  necessary 
in  urgent  cases,  where  we  fear  septic  intoxication  and  the  symptoms 
point  to  septic  absorption  (especially  should  any  complication  have 
occurred    during    operation    to  justify    a    suspicion  of    consequent 


SURGICAL    TREATMENT  OF   UTERINE  MYOMA.  545 

sepsis),  to  opeu  the  wound  at  once  and  examine  it.  The  bowel  in 
contact  with  it  is  examined,  and  the  intestine  is  carefully  covered 
with  hot  sterilized  cloths.  When  the  bowel  has  been  pushed  aside, 
the  pelvic  cavity,  the  stump  of  the  cervix  if  myo-hysterectomy  has 
been  performed,  and  the  pouch  of  Douglas,  are  all  explored,  and, 
should  it  be  necessary,  the  pelvis  is  flushed  out  with  warm  sterilized 
saline  solution. 

Having  thoroughly  disinfected  and  cleansed  the  pelvic  cavity, 
the  lower  portion  of  the  wound  is  left  open,  the  pelvis  is  loosely 
packed  with  sterilized  iodoform  gauze,  and  a  piece  is  allowed  to 
protrude  from  the  lower  end  of  the  abdominal  wound  to  serve  as 
a  drain.  In  these  post-operative  procedures,  chloroform  is  the  best 
anaesthetic  to  select.  We  must  not  forget  the  part  taken  by  the 
Trendelenburg  position  in  the  production  of  ileus,  as,  owing  to  the 
falling  down  of  the  intestines,  a  loop  may  pass  through  an  opening 
in  the  omentum,  and  this  lead  to  strangulation.  Should  we  suspect 
that  ileus  has  supervened,  and  that  there  is  associated  obstruction, 
there  can  be  no  doubt  that  calomel  is  the  sheet  anchor  ;  and  here 
a  dose  of  five  grains  may  be  placed  on  the  tongue,  followed  by  the 
administration  of  a  large  enema.  Should  this  latter  return,  and 
no  motion  follow,  sulphate  of  magnesia,  given  as  we  have  already 
indicated,  is  the  best  saline  purgative  under  the  circumstances,  if 
the  stomach  will  tolerate  it.  If  the  symptoms  persist,  especiallv  if 
there  be  recurrence  of  severe  pain  and  persistent  vomiting,  the 
abdomen  must  be  opened,  and  the  site  of  the  strictured  bowel  be 
sought.  Adhesions  of  coils  of  bowel  to  each  other  or  to  the  stump 
should  be  looked  for,  and  these  must  be  gently  separated,  and  in 
the  most  delicate  manner,  any  tear  being  at  once  repaired  with  fijie 
silk  sutures.  Any  intestinal  injury  caused  in  the  reduction  of  the 
obstruction  should  be  immediately  closed,  and  perfect  cleanliness  of 
the  abdominal  wound  secured. 

In  searching  for  the  source  of  obstruction  in  ileus,  or  in  the  manipulation 
of  adhesions,  ever}'  antiseptic  and  aseptic  precaution  has  to  be  taken,  and  the 
abdomen  and  wound  thoroughly  disinfected  before  the  sutures  are  removed. 
The  temperature  of  the  room  in  which  the  operation  is  performed  should  be 
over  70^.  Every  preparation  must  be  made  to  protect  and  keep  the  bowel 
warm,  the  table  on  which  the  patient  is  placed  should  be  heated  or  covered 
with  hot  blankets,  and  hot  water-bottles  be  ready  for  the  feet :  and  then, 
commencing  at  the  ileo-ccecal  valve,  the  search  is  continued  until  the  limit 
between  the  dilated  and  collapsed  portion  of  intestine  is  reached.  Then  the 
adhesion  is  separated,  or  any  band  is  divided,  the  bowel  returned,  and  the 
abdomen  closed  with  all  the  usual  precautions. 

2  X 


546  DISEASES   OF   WOMEN. 

Injuries  to  the  bladder  and  ureter,  with  resulting  complications, 
require  special  management,  according  to  the  extent  and  character 
of  the  rent  and  its  situation.  These  matters  are  dealt  with  in  the 
chapter  on  the  Bladder  and  Ureters. 

Secondary  Hsemorrhage. — This  is  probably  the  most  serious  of  all 
post-operative  conditions,  and  has  its  commonest  cause  in  the  slip- 
ping of  a  ligature,  or  too  hasty  and  ineffectual  h^emostasis.  Neglect 
in  thoroughly  securing  the  pedicle  of  a  tumour,  and  its  severance 
too  close  to  the  ligature,  are  other  sources  of  secondary  bleeding. 
Some  surgeons  affect  to  despise  that  bleeding,  which  is  said  to  be 
'  only  an  oozing,'  but  which,  if  we  carefully  staunch  the  surface  and 
watch  the  source  from  which  the  blood  comes,  we  shall  generally 
find  is  due  to  one  or  two  small  vessels  which  have  escaped  torsion  or 
ligature. 

It  is  the  complete  control  of  all  bleeding,  and  accurate  peritoneal 
adaptation,  that  stamps  the  operation  as  being  perfectly  and  safely 
finished. 

The  recognition  of  these  facts  by  surgeons,  added  to  the  growing 
determination  not  to  sacrifice  the  safety  of  a  patient  at  the  cost  of 
a  little  extra  time  devoted  to  the  arrest  of  all  bleeding,  has  lessened 
in  recent  years  the  occurrence  of  secondary  haemorrhage. 

In  the  ligature  of  vessels  some  surgeons  prefer  silk  to  catgut,  as  they 
consider  that  it  is  less  likely  to  loosen  or  slip.  This  defect,  to  a  certain 
extent,  depends  upon  the  character  of  the  gut.  I  use  gut  almost  entirely  all 
through  the  operation.  Howard  Kelly  recommends  that  all  large  vessels, 
such  as  the  ovarian  or  uterine,  should  be  tied  first  with  silk,  and  then  the 
open  mouths  caught  and  tied  with  catgut.  It  is  much  safer  not  to  trust  to 
mere  torsion  or  compression  either  with  angiotribe  or  ordinary  hsemostatic 
forceps  in  abdominal  operations. 

Symptoms. — In  their  relative  order  the  following  are  the  most 
striking  evidences  of  haemorrhage  :  There  is  a  sudden  change  in  the 
patient's  condition ;  her  countenance  becomes  more  anxious,  and 
there  is  increasing  restlessness.  This  latter  symptom  quickly 
increases,  the  patient  throwing  her  arms  about  as  well  as  her  legs. 
The  pulse  suddenly  increases  in  rapidity,  is  weak,  compressible,  or 
fluttering.  The  respirations  also  increase  and  become  gasping. 
The  pallor  of  the  countenance,  the  coldness  of  the  extremities,  and 
the  clammy  skin  complete  a  group  of  symptoms  which,  when  followed 
by  a  subnormal  temperature,  are  unmistakable. 

Treatment. — In  the  face  of  such  symptoms  there  is  but  one  course 
to  pursue  :    the  abdomen    has  to  be    reopened,   the  source  of  the 


SURGICAL    TREATMENT   OF    UTERI SE    MYOMA. 


547 


hsemorrhage  sought  for,  and  the  bleeding  vessel  or  vessels  secured. 
But  before  this  is  done,  temporary  means  must  be  at  once  adopted. 
These  consist  of  a  subcutaneous  injection  of  strychnine,  and  the 
administration  of  brandy  by  the  rectum,  this  being  repeated  within 
a  short  time.  Immediately  before  the  opei'ation  is  commenced 
artificial  serum  is  injected.  In  such  cases  time  is  of  the  utmost 
value,  so  that  it  must  not  be  lost  in  too  elaborate  preparations. 

Every  i)ossible  care  is  taken  to  maintain  the  body  temperature 
during  and  after  the  operation.  The  surgeon  and  assistant  having 
sterilized  their  hands,  the  wound  is  opened  from  below,  two  or 
more  sutures  are  divided,  and  the  margins  of  the  abdominal  wound 
having  been  separated,  the  peritoneum  is  caught  well  up  with  catch 
forceps  and  opened.  Immediately,  the  blood  makes  its  appearance 
in  the  wound,  and  simultaneously  two  tingers  are  carried  down  into 
the  pelvis.  The  uterus  will  be  a  guide  to  direct  the  finger.  If  the 
ligature    has    slipped,   both   broad   ligaments   have    to  be   exposed, 


sponges  being  used  to  remove  the  blood,  and  temporary  clamps  arc 
placed  both  on  the  cornu  of  the  uterus  and  on  the  outer  extremity 
of  the  broad  ligament.  This  having  been  done,  and  the  cause  of 
the  bleeding  been  successfully  met,  the  ovarian  vessels  are  secured 
and  the  broad  ligament  is  again  carefully  ligated.  In  a  case  of  pan- 
hysterectomy, the  pelvic  cavity  may  have  to  be  explored,  the  blood 
staunched  as  far  as  possible  after  temporary  clamping  of  the  broad 
ligaments,  and  any  bleeding  points  searched  for.  Here,  again,  both 
uterine  and  ovarian  arteries  are  secured,  and  fresh  ligatures  are 
placed  on  the  broad  ligaments.  If  the  operation  has  been  that  of 
myo-hysterectomy,  the  cervical  stump  is  seized  and  pulled  well  up 
towards  the  abdominal  opening,  so  that  it  may  be  inspected,  and,  if 
the  haemorrhage  proceed  from  it,  a  ligature  is  passed  below  the 
bleeding  point,  and  the  vessel  is  thus  secured.  The  abdominal  wall 
is  closed,  and  it  is  better  to  lose  no  time  by  separate  adaptation  of 
the  parietal  layers,  but  to  close  the  wound  rapidly  by  passing  gut, 


548  DISEASES   OF   WOMEN. 


or  silkwoi'm-gut  sutures  through  the  entire  parietes.  Here  Zweifel's 
through  and  through  needle  is  most  useful  for  rapid  sewing  of  the 
wound.  The  patient  is  now  removed  to  the  warm  bed  which  has 
been  prepared  for  her,  the  foot  of  which  has  been  elevated,  and  a 
submammary  injection  of  artificial  serum  is  given,  with  one  of 
braiady  into  the  bowel.  If  she  be  very  collapsed,  these  had  better 
be  administered  while  she  is  on  the  table  before  removal  to  bed. 
When  there,  a  subcutaneous  injection  of  strychnine  is  given,  and 
this  must  be  contiaued  at  intervals,  care  being  taken  so  as  not  to 
produce  toxic  symptoms  from  the  drug. 

High  Temperature. — While  we  may  take  it  as  the  rule  that, 
excluding  the  ordinary  variations  which  occur  v/ithin  the  first 
twenty-four  hours  or  so  after  operation,  the  aseptic  case  runs  a 
normal  course  with  but  slight  deviation,  rarely  passing  above  99°, 
there  are  others  in  which,  so  far  as  the  wound  or  the  operative 
tract  is  concerned,  everything  is  surgically  perfect,  yet  erratic 
variations  happen  that  it  is  difficult  to  account  for,  and  which  may 
cause  unnecessary  alarm  and  anxiety.  It  is  mainly  in  those  patients 
with  a  nervous  temjDerament  that  such  a  rise  of  temperature  is  met, 
and  unquestionably  the  most  unfavourable  patients  for  abdominal 
operations  are  those  whom  we  should  class  as  neurotic  or  hysterical. 
They  are  the  most  sensitive,  apprehensive,  impatient  of  pain, 
difB-Cult  to  feed,  and  restless.  The  very  restlessness  itself  is  sufficient 
to  disturb  parts,  disarrange  dressings,  elevate  the  temperature  and 
pulse,  upset  the  digestive  functions,  and  predispose  to  mischief  that 
otherwise  would  be  avoided.  There  can  be  no  doubt  that  tempo- 
rary pyrexia  is  often  caused  by  blockage  of  the  bowel,  want  of  care 
in  maintaining  an  even  temperature  in  the  room,  or  in  regulating 
the  covering  of  the  jDatient.  It  also  may  be  the  result  of  an  inju- 
dicious visit  of  a  friend  or  relative,  pain,  slee]plessness,  premature 
administration  of  solid  food,  some  vesical  derangement,  or  the 
toxic  effects  of  iodoform.  The  temperature  rises  from  irritation 
in  the  track  of  the  abdominal  wound,  the  collection  of  serum 
in  the  neighbourhood  of  the  sutures,  or  threatening  of  stitch- 
abscess.  On  the  whole,  however,  it  is  always  safest  to  look  upon 
an  elevation  of  temperature  as  a  danger  signal,  and  one  not  to  be 
neglected.  The  ranges  of  peritonitis  and  septicaemia  are  unmis- 
takable, though  it  does  occur  that  an  abnormal  temperature  will 
sometimes  attend  upon  the  course  of  a  perfectly  straight  surgical 
convalescence.  A  few  doses  of  phenacetin  or  antipyrin  given  in 
cachets,  washed  down  with  an  effervescing  citrate  of  potash  mixture. 


ftrnn/CAL  theatment  of  rTEnrsK  myoma.  mii 

is  a  simple  hut  generally  successful  method  of  meeting  some  rise  of 
temperature  whifh  has  not  any  infective  origin.  A  few  grains  of 
(juinine  may  be  combined  in  each  cachet.  A  saline  purgative  and 
a  grain  or  two  of  calomel  are  given,  and  the  bowel  is  opened. 
Absolute  quiet  is  secured,  and  the  visit  of  any  friend  is  prohibited. 
The  elevation  of  temperature  caused  by  peritonitis,  sepsis,  or 
stitch-abscess  is  treated  in  the  manner  described  in  discussing  these 
complications. 

Fiecal  Fistula. — If  after  an  abdominal  or  vaginal  operation  a 
fsBcal  tistula  should  result  from  injury  to  the  bowels,  or  necrosis  from 
pressure,  the  first  principle  is  to  keep  the  fistulous  canal  isolated  as 
far  as  possible,  while  steps  are  taken  to  disinfect  it.  Dressings  or 
tampons  that  indicate  by  the  odour  or  discharge  that  fitcal  matter 
is  present  must  be  frequently  changed,  and  the  skin  round  the  wound 
kept  scrupulously  clean. 

If  the  fistulous  opening  be  on  the  abdominal  wall,  a  few  loops  of 
the  ligatures  should  be  divided  and  the  fistula  washed  out  with  a 
formalin  solution.  By  injecting  a  warm  saline  solution  into  the 
rectum,  should  the  fistula  have  its  origin  here,  the  fluid  wells  up 
through  the  abdominal  opening,  and  a  long  flexible  probe  passed 
down  the  fistula  will  determine  this.  Such  washings  are  daily 
repeated.  With  a  long  crochet  needle  or  hook  the  canal  may  be 
searched  for  any  retained  ligatures,  which  then  are  detached,  or  if 
possible,  cut. 

If  despite  all  such  efforts  the  fistula  will  not  heal,  then  there  only 
remains  the  radical  operation  of  cutting  down  on  and  isolating  tho 
fistulous  track,  dissecting  it  out,  if  this  be  possible,  and  closing  the 
bowel  opening  by  sutures,  or  enveloping  it  with  a  gauze  pack,  so  as 
to  induce  the  formation  of  new  granulation  tissue.  An  attempt  is 
made  at  the  same  time  to  cover  it  with  pei'itoneum  and  adjacent 
bowel. 

If  fpecal  matter  escape  and  find  its  way  on  to  the  dressings  after 
a  vaginal  hysterectomy,  the  rectum  must  be  kept  well  cleansed 
with  boric  acid  and  formalin  injections,  f cecal  accumulations  pre- 
vented, and  the  vagina  should  also  be  douched  four  or  five  times  in 
the  day.  If  there  be  any  suspicion  of  pent-up  matter,  and  the 
sutures  have  not  been  removed,  these  should  be  cut  and  withdrawn. 
A  gauze  drain  is  kept  against  the  opening,  and  a  free  vent  for  any 
discharge  is  allowed.  Any  attempt  to  close  the  rectal  fistula  must 
be  postponed. 


CHAPTER  XXX. 
CANCER  OF  THE  UTERUS. 

Etiological — Pathological. 

According  to  its  location,  cancer  of  the  uterus  may  be  limited  to 
the  body,  the  cervix,  or  the  portio  vaginalis.  We  thus  speak  of 
'  cancer  of  the  body,'  '  cancer  of  the  cervix,'  and  '  cancer  of  the 
portio  vaginalis.'  And  this  clinical  division,  according  to  the 
location  of  the  disease,  has  its  justification  on  strict  grounds  of 
pathological  difterentiation.  The  classification  of  the  older  writers 
into  medullary,  epitheliomatous,  and  scirrhoid  has  still  its  clinical 
significance.  Yet  malignant  disease  is  found  both  in  the  cervix 
and  body  of  the  uterus,  in  the  former  mainly  as  malignant  adenoma, 
adeno-carcinoma,  and  adeno-sarcoma,  while  in  the  body  we  fi.nd 
carcinoma,  sarcoma,  and  myo-sarcoma,  more  frequently.  Certain 
types  of  papilloma  are  associated  both  with  the  benign  and  malig- 
nant growths,  as,  for  example,  papillary  adeno-sarcoma  and  papillary 
cysto-adeno-sarcoma.  Papillary  outgrowths  of  a  cartilaginous,  myxo- 
matous and  adeno-myxomatous  nature  have  been  recorded  of  the 
malignant  type  (Munde,  Thiede,  Winckel).  Calcareous  and  fatty 
degenerations  have  been  found  associated  with  those  of  the  carci- 
nomatous kind. 

Malignant  Adenoma  of  Cervical  Glands.^^-AIfred  Smith  reported  a  case  of 
malignant  adenoma  of.  the  cervical  glands.  The  uteras  was  removed  by 
vaginal  hysterectomy.  The  recovery  was  uninterrupted.  *  Malignant  adenoma 
of  cervical  glands  is,  according  to  C.  Gebherd,*  extremely  rare ;  he  can  only 
find  a  record  of  six  cases.  Ruge  and  Veit  f  say  that  cases  of  adenoma  in  the 
pure  form  are  seldom  met  with,  and  Brose  J  agrees  with  them  also  in  the 
extreme  rarity  of  this  affection.  Smith's  specimen  microscopically  showed 
the  upper  portion  of  the  cervical  canal  greatly  distended  and  excavated. 
The  lower  portion  was  apparently  normal.  The  microscopic  section  showed 
a  columnar  cell  epithelioma.'  § 

*  Zeitsch.  f.  Gehurtsh.  u.  Gyn.,  bd.  xxxiii.,  heft  3,  1895. 
t  Idem.,  170.         J  Idem.,  134.  §  Medical  Press  and  Circular,  1895. 


CANCER    OF  THE    UTERUS.  5")! 


Recent  Researches  on  the  Pathogeny  of  Cancer. 

The  recent  researches  of  Bretland  Farmer,  J.  E.  S.  Moore,  and  C.  E. 
Walker,  brought  before  the  Royal  Society  *  are  of  extreme  interest, 
as  throwing  an  important  light  on  the  initial  cell  changes  that  occur 
in  the  transformation  and  spread  of  a  malignant  growth.  "These 
researches  would  tend  to  show  that  the  serial  cell  changes  of  an 
invading  and  proliferating  malignant  tissue  are  very  '  similar  to 
those  obtaining  during  the  maturation  of  the  elements  contained 
within  the  sexual  reproductive  organs,'  even  extending  to  '  minute 
points  of  detail.' 

When  segmentation  of  an  ovum  occurs,  *  the  nuclei  of  all  the  resulting  cells 
are  found  to  contaia  a  definite  number  of  chromosomes  during  each  nuclear 
division.'  The  evolutionary  changes  through  which  the  chromosomes  pass 
are  as  follows : — There  is  an  aggregation  of  granules  of  a  stainable  substance 
(chromatin)  arising  out  of  the  material  from  which  the  chromosomes  originate 
as  definite  structures.  They  are  constant  in  number  for  each  species  of  animal 
or  plant,  and  divide  longitudinally  into  two  daughter-chromosomes,  and  in 
their  division  are  arranged  in  a  definite  manner  on  the  spindle,  frequently 
appearing  as  V^s,  mith  the  apex  directed  towards  the  axis  of  the  spindle. 
Fission  provides  the  twin  nuclei,  and  these,  whenever  new  somatic  cells  are 
formed,  undergo  simdar  division.  In  the  case,  however,  of  the  sexual 
elements,  the  gamotogenic  cells,  which  are  the  source  of  the  former,  can  be 
differentiated  from  the  somatic  at  a  very  early  period,  or  may  only  be  capable 
of  demonstration  further  on.  The  somatic  and  gamotogeniccells  differ  in  the 
process  of  mitosis,  in  the  period  of  rest  and  growth  ;  the  gamotogenic  chromo- 
somes formed  from  the  resting  nucleus  are  only  half  in  number  as  compared 
with  those  present  in  the  dividing  nuclei  of  the  somatic  chromosomes ;  the 
form  of  the  gamotogenic  and  somatic  chromosome  is  markedly  different ;  the 
fission  in  the  former  is  transverse  and  not  longitudinal.  The  descendants  of 
gamotogenic  cells  retain  under  normal  conditions  the  reduced  number  of 
chromosomes  mentioned,  and  the  cycle  of  cell  generations  ends  in  the  forma- 
tion of  ova  or  spermatozoa.  When  the  fusion  of  the  two  occurs,  the  somatic 
number  is  restored,  this  being  characteristic  of  the  fertilized  ovum  and  the  cells 
into  which  it  di\ndes  until  the  peculiar  transverse  division  in  the  gamotogenic 
cells  makes  its  appearance.  After  such  division  a  further  cleavage  may  produce 
four  sexual  cells.  In  the  case  of  plants,  this  arrangement  is  not  so  definite  in 
the  number  of  cell  generations  before  the  ultimate  sexual  cells  are  evolved. 

Applying  this  knowledge  to  the  pathology  of  a  rapidly  growing  epithelioma, 
in  the  earlier  proliferation  of  the  Malpighian  layer,  the  characteristic  somatic 
division  is  observed  '  exactly  as  in  the  earlier  stages  of  reproductive  tissues.' 
But  '  as  the  multiplication  proceeds,  however,  a  change  passes  over  the  cells 
themselves.  The  protoplasmic  continuity  to  which  the  "  prickly  "  character  is 
due,  becomes  more  or  less  obliterated,  and  the  cells  assume  that  appearance 

*  December,  1903. 


552  DISEASES   OF   W03fEK 

of  indifferent  germ  tissue  so  well  known  as  a  feature  of  the  elements  of  which 
such  are  largely  made  up.' 

The  point  of  extreme  significance  is  this,  that  in  the  zone  behind  the 
advancing  edge  of  the  neoplasm,  enlarged  cells  are  seen,  each  containing  a 
nucleus  of  large  size.  As  fission  occurs,  its  chromosome  is  in  the  form  of  a 
thickened  loop  or  ring,  tvMch  splits  transversely,  as  in  the  case  of  pro- 
nuclear  division  of  the  normal  reproductive  tissue,  and  in  number  these 
chromosomes  are  less  than  in  the  normal  somatic  cells  of  the  surrounding 
tissue  as  in  the  case  of  the  gamotological  cells.  Such  phenomena  occur  in 
other  tj^pes  of  malignant  disease  as  well  as  epithelioma,  but  in  benign  tumours 
they  are  absent. 

The  authors  of  these  researches  regard  the  transplantation  or  trans- 
raissibihty  of  malignant  disease  from  individual  to  individual  as  possible, 
'  where  it  is  conceivable  that  the  repeated  application  of  a  suitable  stimulus 
or  of  the  continuous  introduction  of  cells  which  have  undergone  the  changes 
(they  have  described)  can  happen.' 

The  Correlations  of  the  Pelvic  Lymphatics  in  Malignant  Disease 

of  the  Uterus. 

Emil  Ries  of  ChicagOj*  who  has  removed  the  pelvic  lymphatics  with  the 
carcinomatous  cervix  since  1895,  speaking  from  the  examination  of  some 
twenty  thousand  sections,  says,  that  '  carcinoma  of  the  uterus  invades  the 
pelvic  lymphatics,  just  as  early  and  with  as  much  certainty  as  carcinoma  of 
other  organs  invades  the  regional  lymphatics,'  He  asserts  the  identity  of  the 
carcinomatous  structure  of  the  gland  with  that  of  the  original  carcinoma,  both 
in  the  cell,  the  cell  arrangement,  and  the  progress  of  the  change.  A  specimen 
in  his  possession  proves  beyond  possibility  of  doubt  that  '  particles  of  carcinoma 
are  carried  away  from  the  original  seat  of  the  cancer  by  the  lymph  current, 
and  begin  to  grow  in .  the  new  location.'  Hence,  in  '  our  operations  it  is 
always  unsafe  to  cut  between  the  regionary  lymphatics  and  the  original 
carcinoma,  as  we  never  know  where  we  may  come  across  carcinoma  in  the 
course  of  the  operation.' 

Tlie  invasion  takes  place  in  the  connective  tissue  of  the  hilus,  next  in  the 
germinal  centres  of  a  few  follicles  or  medullary  cords,  so  that  follicular  cavities 
are  formed  by  pressure.  This  invasion ,  proceeds  until  the  entire  gland 
becomes  a  carcinomatous  nodule,  and  only  by  the  remaining  follicle  or 
medullary  cord  can  we  ascertain  that  a  structure  is  glandular.  These 
follicular  cavities  may  fill  with  extravasated  blood  or  degeneration  products, 
and  the  cysts  formed  may  coalesce,  creating  a  hollow  mass  of  carcinoma 
easily  bursting  during  attempts  at  removal.  These  affected  glands  are  not 
necessarily  large,  or  vice  versa.  Ries  draws  attention  to  the  presence  of 
epithelial  ducts  in  the  lymphatic  gland,  either  in  its  capsule,  the  trabecute, 
or,  later  on^  entering  into  its  tissue,  hut  always  folloiving  the  course  of  the 
traheculm.  The  ducts  are  composed  of  low  or  high  columnar  cells,  sometimes 
with  bristles  at  the  top,  and  with  a  nucleus  in  the  middle  of  the  cell.  They- 
are  either  straight  or  ramified,  are  surrounded  by  connective  tissue,  and  their 

*  Amer.  Gyn.,  July,  1903. 


CAXCEB    OF   THE    UTERUS.  553 


contents  either  degenerative  cells  or  leucocytes.  The  stratified  nature  of  the 
original  carcinoma  in  some  of  his  cases  made  it  quite  clear  that  these  epithelial 
ducts  did  not  harmonize  with  it.  There  may  he  an  adeno -myoma  present 
with  tlie  carcinoma,  and  Kies  thinks  that  the  connection  between  the  posterior 
pelvic  wall  and  the  Wolffian  body  from  which  adeno-myomas  originate  is  so 
close  that  it  is  quite  possible  that  its  remnants  may  have  become  embedded 
in  the  lymphatics  located  on  the  posterior  pelvic  wall.  Hence,  the  presence 
of  these  epithelial  ducts. 

Ries  also  notices  the  large  cell  hyperplasia  and  the  hyaline  degeneration 
which  are  present  in  the  connective  tissue  stroma  of  the  glands,  affording 
an  explanation  of  the  calcareous  deposit  which  is  found  in  the  degene- 
rating h'mphatic  glands;  a  fatty  degeneration  is  also  present.  This  fatt}' 
metamorphosis  led  Ries  to  believe  that,  'seeing  it  is  found  under  normal 
conditions,  in  the  lymphatic  system,  a  constant  fluctuation  is  taking  place, 
new  glands  forming  as  older  ones  lose  their  function,  this  occurring  anywhere 
in  the  connective  tissue.' 

The  presence  of  hfcmo-lymph  glands  containing  red  blood  corpuscles  mixed 
with  leucocytes  has  also  been  established  by  Warthin  (Michigan)  and  been 
confirmed  by  Ries.  '  With  their  direct  communication  with  the  blood-current 
they  offer  an  entirely  new  explanation  of  the  different  ways  in  which  carci- 
noma of  the  uterus,  or  anywhere  else  in  the  body,  may  form  metastases. 
Formerly,  it  has  been  assumed  that  carcinoma  proceeds  along  the  lymphatics. 
If  carcinoma  proceeds  to  a  lymph  gland  which  is  in  connection  with  the  blood- 
current,  there  is  nothing  to  prevent  the  carcinoma  from  pervading  the  whole 
system.' 

Gellhorn  *  (see  also  p.  554),  in  a  survey  of  the  whole  question  of  lym- 
phatic infection,  arrives  at  the  conclusion  that,  while  the  lymphatic  system  is 
the  avenue  along  which  the  disease  travels,  it  by  no  means  follows  that  the 
lymph  glands  are  early  involved.  The  regional  pelvic  glands  are  affected  in 
some  one-third  of  the  cases,  especially  where  the  primary  cancer  involves  the 
parametria  and  adjacent  structm-es,  but  not  as  a  rule  in  the  early  stages  of 
the  disease.  The  disease  may  travel  by  the  path  of  the  lymph  radicals  and 
the  lymph  spaces  of  the  nerves,  and  the  sacral  plexus  may  thus  be  attacked. 
The  portio  vaginalis,  the  vagina,  the  paravaginal  tissue,  and  the  connective 
tissue,  are  successively  invaded,  and  much  more  commonly  than  the  bladder 
and  rectum. 

Carcinoma  (Adeno-Carcinoma)  of  the  cervix  generally  proceeds  through  the 
cervical  tissues  horizontally,  or  invades  the  corpus,  and,  not  so  often,  the 
vagina,  while  the  involvement  of  the  pelvic  glands  is  relatively  more  frequent, 
and  takes  place  in  an  earlier  stage  than  when  the  vaginal  portion  is  affected. 
In  cancer  of  the  body  there  is  slower  extension  of  the  disease,  and  a  greater 
tendency  to  its  limitation  to  the  uterine  cavity,  nor  are  metastases  so  frequent. 

Implantation  Metastases. — Olshausen  has  recorded  several  cases  of  im- 
plantation metastases  in  the  abdominal  wall.  Six  of  these  occurred  at 
varying  periods  after  the  removal  of  malignant  ovarian  tiimours,  and  two 
cases  after  extirpation  of  a  carcinomatous  uterus.     The  latency  of  the  cancer 

*   Amer.  Oyn.,  Nov.,  1902. 


554  DISEASES   OF    WOMEN. 

in  some  of  these  cases  is  remarkable.  Purefoy  has  recorded  a  case  of  a 
secondary  growth  in  the  abdominal  cicatrix  after  hysterectomy,  and  one  after 
the  removal  of  an  ovarian  cyst. 

Anatomy  of  Pelvic  Lymphatics  and  Glands, — In  regard  to  the  anatomy  of 
the  lymphatic  vessels  and  glands  of  the  pelvis,  Gellhorn,*  from  the  researches 
of  Sappey,  Poirier,  Paissell,  Piser,  Bruhns,  and  Waldeyer,  notices  their  regu- 
larities in  the  distribution  of  the  pelvic  lymphatics.  An  important  gland 
is  the  utero-vaginal,  a  short  distance  from  the  cervix  in  the  parametrium. 
The  lymph  channels  of  the  cervix,  and  the  upper  third  of  the  vagina, 
lead  to  the  hypogastric  glands,  at  the  bifurcation  of  the  common  iliacs, 
and  their  vasa  efferentia  proceed  to  the  external  iliac  glands,  which  are 
the  continuation  of  the  lympho-glandulje  subinguinales  profundae  in  the 
retro-inguinal  space  of  Waldeyer,  adjacent  to  the  external  iliac  arteries 
and  veins.  Along  the  course  of  the  common  iliacs  are  found  the  inferior 
lumbar  lympho-glandulse,  and  lymph  vessels  pass  out  from  the  cervix 
into  the  sacro-uterine  ligaments,  and  discharge  into  the  sacral  glands. 
These  are  situated  on  the  anterior  surface  of  the  sacrum,  and  in  the  course 
of  the  arteria  sacralis  media.  From  the  sacral  glands  there  is  a  com- 
munication with  the  common  iliac  glands.  The  majority  of  the  lymphatics 
supplying  the  body  of  the  uterus  at  either  side  form  two  large  vessels 
which  pass  outwards  along  the  upper  border  of  the  broad  ligament.  These 
receive  the  lymph  vessels  of  the  ovaiy,  and,  ascending  by  the  ovarian 
artery,  they  enter  into  the  median  group  of  lumbar  glands,  which  lie 
directly  in  front  of  the  aorta  and  inferior  vena  cava,  partly  surrounding  these 
vessels,  and  being  connected  with  all  the  other  glands  mentioned.  The 
lymphatic  vessels  from  the  comu  and  Fallopian  tube  pass  out  within  the  round 
ligaments,  and  empty  into  the  upper  gland  of  the  inguinal  groups.  The  topo- 
graphical distribution  of  the  lymph  vessels  and  glands  is,  as  has  been  said, 
inconstant  and  by  no  means  regular.  Seelig  has  demonstrated  in  his  inaugural 
dissertation  (Strasburg,  1894),  that  small  lymph  vessels  receiving  the  lymph 
fluid  from  the  larger  lymph  spaces  in  the  uterus  lined  with  epithelium,  empty 
into  other  jjerivascular  IjTnph  vessels  between  the  median  and  other  muscular 
layers  of  the  uterus,  anastomosing  freely  with  one  another.  The  carcino- 
matous cells  emanate  from  the  borders  of  the  uterus  into  the  larger  lymph 
vessels  above  referred  to. 

Involvement  of  Nerve  Trunks. 

Spread  of  Infection  by  Nerve  Trunks. — Ernst  has  shown  f  that  cancer  attacks 
adjacent  nerve  trunks  by  way  of  the  lymph  radicals  and  lymph  spaces  of  the 
nerve  involving  the  perineurium,  and  more  particularly  the  endoneurium, 
separating  the  nerve  sheath,  the  cancer  cells  covering  the  connective  tissue 
membranes  as  an  epithelial  layer,  and  there  proliferating.  The  endothelial 
lining  of  the  lymph  capillaries  is  finally  destroyed  ;  the  nerve  trunk  proper  is 
separated  into  numerous  bundles  by  the  invading  cancer.  Ernst  injected  from 
the  sciatic  nerve  the  entire  pelvic  lymphatic  system  as  high  as  the  lumbar, 
glands.     Cancer  also  spreads  by  the  vagina  or  paravaginal  tissue,  whence  it 

*  Amer.  Gyn.,  1902.  t  Centralb./.  Gyn.,  1902,  No.  88. 


CANCEL'    OF    THE    UTERI'S.  SSS 


spreads  to  the  connective  tissue  of  the  pelvis.  Cancer  recurrence  after 
operation  in  three-foiu'ths  of  all  cases  occurs  in  or  near  the  vaginal  scar. 
Mackenrodt's  higher  percentage  of  recurrence  in  the  glands  was  due  to  the 
inoperative  nature  of  the  cases. 

Kies,*  remarking  on  the  difficulty  of  finding  carcinoma  in  the  glands,  states 
that  he  examined  700  sections  in  one  case  before  he  discovered  the  carcinoma, 
and  he  endorses  the  view  that  the  enlarged  glands  may  not  be  malignant,  and 
that  the  ratio  between  the  size  of  the  cancer  and  that  of  the  aifected  gland, 
either  in  point  of  numbers  or  extent  of  invasion,  is  uncertain.  Tiiey  are 
frequently  not  often  discovered  until  the  peritoneum  is  opened  and  the  large 
vessels  exposed. 

Parametric  Invasion. — Wakefield,!  from  his  investigations,  comes  to  these 
conclusions  : — (a)  That  parametric  invasion  generally  precedes  the  infection 
of  lymph  nodes,  it  being  the  first  tissue  involved,  and  its  invasion  is  not 
necessarily  attended  by  either  palpable  or  ocular  proof  of  the  infiltration.  On 
the  other  hand,  the  thickening  and  induration  of  the  parametrium  is  no  pi'oof 
of  malignant  extension,  {b)  AYhile  enlarged  lymph  nodes  are  not  necessarily 
cancerous,  the  context  is  equally  true.  The  most  minute  microscopic  examina- 
tion of  lymph  nodes  in  serial  sections  is  required  before  a  conclusion  is  arrived  at. 

Simple  hypersemia,  hyperplasia,  secondary  infection  with  pyogenic  bacteria, 
the  deposition  of  cancer  elements  in  the  node,  are  all  distinct  causes  of 
enlarged  and  diseased  lymph  nodes.  It  has  also  to  be  remembered  that 
structures  closely  resembling  those  of  glands,  but  differing  in  their  cellular 
construction,  are  present.  Wakefield  does  not  agree  with  the  view  that 
these  embryologic  stmctures  arise  from  abnormal  inclusion  of  parts  of  the 
Wolffian  body.  Where  there  are  no  evidences  of  cancer,  these  structures 
were  not  found.  In  the  same  node  three  distinct  stages  were  found  associated 
with  cancer:  (1)  simple  gland-like  formations;  (2)  gland-like  structures 
suiTounded  by,  and  partially  filled  with  epithelial  masses  ;  (3)  purely  carci- 
nomatous deposit. 

Mary  Dixon  Jones,  in  an  investigation  of  cancer  of  the  perimetrium,  com- 
ments on  the  absence  of  all  normal  epithelial  structure,  and  the  presence  of 
columnar  epithelium  of  the  adenoid  A-ariety.  Active  proliferation  of  the 
epithelia  (Virchow)  tends  to  new  formations  and  an  inflammatory  proliferation, 
infiltrating  the  connective  tissue  with  granules  and  globules  adjacent  to  the 
cancer  nests,  there  being  a  gradual  reduction  of  new  gi'owth  to  an  embrj'onal 
or  medullary  condition.  Inflammatory  corpuscles  shape  themselves  into  cancer 
epithelia,  and  the  medullary  corpuscles  form  cancer  nests.  In  fact  (Heitz- 
mann).  the  '  small  cellular  infiltration '  (Fig.  401)  is  the  fore  stage  of  cancer.' 
Such  infiltration  is  a  sure  means  of  prognosis  of  return  of  cancer  in  the  spot. 

'It  is  the  chief  zone  of  local  recurrences  after  extirpation.'  No  longer  can 
the  presence  of  cells  be  regarded  as  essential  to  proliferation,  and  we  must 
seek  in  the  fibrous  basis  substance  for  the  transformation  into  protoplasm.  In 
it  are  generated  the  cancer  epithelia.  Further  microscopical  investigation  in 
this  case  showed  the  following  points  of  pathological  interest  :  (1)  rows  of 
cancer  cells  in  the  lymph  vessels,  dflated  by  and  caiTying  these ;  (2)  thrombosis 

*  Amer.  Jour.  Ohstet.,  July,  1901.  t  Amer.  Jour.  Obstet.,  Oct..  lOOo. 


556  DISEASES   OF    WOMEN. 

by  the  cancer  epithelia  of  the  true  lymph  vessels  (Fig.  402);  secondary 
changes  in  the  vicinity  of  the  invaded  lymphatics  ;  (4)  degenerating  changes 
in  the  lymph  vessels,  walls,  and  adjacent  connective  tissue.  Thus,  the  spread- 
ing of  the  cancer  by  the  lymph  vessels  is  established. 

'  Under  a  power  of  twelve  hundred  diameters  the  cancer  nuclei  become 
coarsely  granular,  undergo  division  into  smaller  pieces  of  protoplasm,  or,  as 
some  say,  there  is  a  "  wild  evolution  of  cells."  Thus,  the  nuclei  break  up 
into  a  number  of  irregular  masses  of  living  matter,  each  one  becoming  an 
active  centre  of  infection.  They  invade  the  lining  endothelia  of  the  lymph 
vessels.  These  endothelia  become  enlarged,  filled  with  granular  matter,  and 
also  undergo  paracinesis  division.  Changes  take  place  in  the  wall  of  the 
lymph  vessels,  they  melt  away,  and  the  cancer  passes  into  new  fields,  taking 
possession  of  new  and  larger  territories,  still  growing  and  spreading.  Under 
the  microscope  the  tissues  around  the  lymph  vessel  were  found  filled  with 
cancer  epitheha  ;  even  the  fibrous  connective  tissue  surrounding  the  thrombus 
was  in  a  state  of  active  proliferation. 

Heterologous  Cancer  Elements  in  Pelvic  Carcinoma. — The  same 
authority  has  recoi'cled  cases  in  which  different  types  of  malig- 
nancy wei-e  present  in  the  pelvic  tissues,  as  seen  in  the  accompanying 
drawings  of  her  sections.  Bearing  on  this  point  of  mixed  types  of 
malignant  disease  occurring  in  conjunction  in  the  same  areas  of 
invasion,  the  case  of  a  mammary  tumour  removed  by  me  may  be 
instanced.  In  some  parts  the  elements  were  those  of  scirrhus,  in 
others  of  adenoma,  while  the  greater  portion  presented  the  typical 
character  of  cystic  sarcoma. 

Heterologous  Elements  occurring  in  a  Case  of  Carcinoma  of  the 
Perimetrium.     (M.  Dixon  Jones.) 

It  is  not  necessaiy  to  discuss  here  the  theory  of  Dumaire  and 
others  of  the  coccidial  theory  of  cancer,  as  it  has  been  shown  that 
these  supposed  parasitic  bodies  are  secondary  formations  found  in 
the  epithelial  tissues,  and  not  psorosperms,  as  was  supposed.  It  is 
true  that  Leopold,  with  Rosental,  found  blastomycetes,  and  with 
the  pure  culture  obtained  they  produced,  from  the  testicle  of  a  rat, 
nodules  in  the  peritoneum ;  they  also  got  blastomycetes  from  these 
nodules,  which  gave  pure  cultures.* 

Scheurlen's  statement  that  he  has  discovered  a  morphologically 
distinct  cancer  bacillus  has  not  been  substantiated  by  subsequent 
observers,  Sanger  and  Virchow  proving  that  this  bacillus  grew  on 
potato  sections  without  cancerous  origin ;  "j"  nor  were  Ballance  and 

*  La  Gynecologie,  Oct.,  1900. 

t  The  researches  of  Farmer  and  Moore  .(page  551)  would  seem  to  dispose 
finally  of  the  bacillus  theory. 


CANCER    OF   THE    UTERUS. 


557 


c  ah 

Fig.  400. — Sciuhhcs  axd  Adenoid  Portion',     (x  200.) 

a.  Longitudinal  bundles  of  coarse  fibrous  connective  tissue ;  h,  small  nests  of 
cancer  epitbelia  (the  scirrhus  portion) ;  c,  gland-like  formations  of  cancer 
epithelia,  the  adenoid  portion. 


-Adenoid  and  MEDrLLAET  Portion 


A 

(  X  200.) 

-•1,  medullary  portion  of  cancer;  B,  adenoid  or  gland-like  formations  of  cancer 
epithelia ;  C,  so-called  small  cellular  or  inflammator}-  infiltration  of  fibrous 
connective  tissue :  B,  longitudinal  bundles  of  coarse  fibrous  connective 
tissue  with  formations  of  nests  between  the  bundles. 


n  m  L  L'  (J 

Fig.  402. — Thrombosis  of  Lymph  Vessel  of  Left  OvAuy  with  Cancer 
Epithelia.     (x  600.) 

0,  Fibrous  connective  tissue  of  medulla  of  ovary  near  hilum ;  n,  bundles  of 
smooth  muscle  fibres ;  m,  lymph  vessel  with  imchanged  endothelial  lining ; 
i,  cancer  epithelia  filling  and  extending  the  calibre  of  lymph  vessel :  JJ . 
cancer  epithelia  whose  nuclei  show  karyokinetic  figures. 


558  DISEASES   OF    WOMEN. 

Shattock,  in  their   experiments   with  cultivations  of  the  microbe, 
able  to  propagate  the  disease  by  inoculation. 

The  Uterine  Vascular  Supply  and  Cancer.— Russell  of  Baltimore 
has  made  some  valuable  researches  on  the  relationship  of  cancer  to 
the  uterine  vascular  supply  and  the  lymphatic  distribution.* 

Gkoup  I.— Uterine  artery^  .  rGiands  found  in  the  parame- 

and  branches  with  the  ?^^^^  ^^  trium     at    broad    ligament 

„         •             If  vag^ma — upper     <  ,             /~,i      ,    ^       f 

accompanying        lym-  th'-l                     ^'^^^^     Grlands  found  at  di- 

phatics.  J  ■  \  viding  points  of  iliac  vessels. 
Geoup  II. — Ovarian  arte-rBody  of  uterus  andj 

ries  and  branches  withj  upper  portion  of  I  Lumbar  glands, 

its  lymphatics.                 (.  broad  ligament,    j 

Group    III. — Vessels    off  Eound  ligament :  w       .,-,-, 
,     .  {  c    J.  Ungiunal  glands, 

uterme  cornu.  I    cornu  of  uterus.    J     ^  ° 

Furneaux  Jordan  thus  epitomizes  the  conclusions  to  be  drawn 
from  Russell's  investigations  : — 

(1)  In  cancer  of  the  portio  vaginalis,  if  the  case  be  suitable  for  operative 
treatment,  a  wide  removal  of  the  vagina  is  indicated. 

(2)  If  the  local  extirijation  be  complete  the  prognosis  is  good. 

(3)  Growths  of  the  cervix  are  usually  adeno-carcinomata  and  are  most 
malignant.     The  parametrium  should  be  removed  as  completely  as  possible. 

(4)  Adeno-carcinomata  of  the  body  are  most  accessible  to  operative  proce- 
dure and  give  the  most  favourable  prognosis. 

(5)  Hysterectomy  for  cancer  of  the  body  should  include  wide  removal  of 
broad  hgaments,  tubes,  ovaries,  and  round  ligaments. 

(6)  The  pelvic  glands  should  be  enucleated  if  possible. 

(7)  Every  precaution  should  be  taken  to  avoid  implanting  cancer  cells  on 
raw  surfaces. 

Medullary  Cancer. — Dependent  upon  the  relative  proportion  of 
connective-tissue  elements  and  epithelial  cells  contained  in  its  trabe- 
cular framework,  we  describe  the  cancer  as  hard  or  soft.  In  the 
medullary  cancer  there  is  a  preponderance  of  the  epithelial  masses 
of  cells,  which  form  plugs  in  the  uterine  tissue,  under  the  mucous 
membrane,  invading  the  areolar  elements.  This  invasion  proceeds, 
both  in  an  outward  direction  and  inwards  towards  the  cavity  of  the 
uterus.  The  areolar  structure  is  compressed  by  the  great  growth 
of  cells,  which  ultimately  soften,  degenerate,  and  break  down  into 
cancer-juice.  This  process  of  cell-proliferation  involves,  after  a 
time,  the  vaginal  roof,  and  then  begins  that  peculiar  fixation  of  the 
uterus  so  characteristic  of  malignant  disease.  This  infiltration  may 
extend   beyond  the  vaginal   roof,   attack    the    pelvic   viscera,    and 

*  Amer.  Jour.  Obstet.  and  Gynecology,  1896. 


CASCEM    OF   THE    UTERUS. 


55'.t 


reach  the  lymphatics.  For  a  considerable  time  the  ulceration  may 
not  attack  the  body  of  the  uterus,  destroying  only  the  cervix ;  but 
ultimately  the  body  of  the  womb  is  in^"aded,  This  cell-growth  leads 
to  death  of  the  areolar  tissue,  softening,  and  ulceration. 

Meantime  the  vessels  supplying  the  cervical  villi  have  increased 
in  size  ;  the  latter  have  also  become  enlarged  and  hypertrophied. 
A  papillomatous  condition  is  the  result.  These  papillae,  situated  on 
a  hardened  and  infiltrated  base,  are  prone  to  bleed.     Commencing 


Fig.  40o. — AoEXu-CARciNuiiA  of  the  Ceuvls.  with  Hyurouketei;  of  Both 
Su>ES.  (HowAUD  Kelly.) 
The  disease  stops  abruptly  at  the  junction  of  the  body  with  the  cer\-ix ;  below, 
it  extends  well  out  into  the  vaginal  vault  and  the  right  broad  ligament, 
and  involves  the  entire  thickness  of  the  cervix.  The  right  ureter,  seen  cut 
across,  is  converted  into  a  large  hydroureter.  On  the  left  side  two  ureters 
are  seen,  which  were  also  converted  into  hydrouretera  of  lesser  degree. 

as  papillary  hypertrophy,  the  malignant  type  is  assumed,  and,  later 
on,  nests  of  epithelial  cells  form  plugs  in  the  submucous  tissue. 
Kapid  cell-proliferation,  great  increase  in  the  villi,  enlargement  uf 
the  vessels,  and  accompanying  degeneration  and  liquefaction  of  the 
cells,  result  in  a  sprouting  or  vegetating  papillary  growth,  the 
caulijlower  excrescence  of  the  older  authors.  Grouping  together  the 
researches  of  Klebs,  Waldeyer,  Virchow,  Ruge  and  Teit,  we  trace 
the  origin  of  all  cervical  malignant  growths,  either  to  (a)  the 
cubical  epithelium  of  the  cervical  glands :  (h)  the  deepest  layers  of 
squamous  epithelium  on  the  vaginal  aspect  of  the  cervix  :  (c)  the 


560 


DISEASES   OF    WOMEN. 


connective  tissue  cells  of  cervix  ;  (d)  the  epithelium  of  the  cervical 
canal. 

Illustrating  the  importance  of  careful  microscopical  examination 
of  the  curettings  where  malignancy  of  the  uterus  may  be  suspected, 
the  following  cases  are  of  interest.  All  three  were  treated  in  the 
same"  manner.      The  uterus   was  thoroughly   dilated,    the    curette 


Fig.  404.     (Authoe.) 

a,  A  collection  of  round  and  irregular  large  and  small  cells,  h.  Largo  space, 
probably  vascular ;  c,  loose,  succulent  connective  tissue,  many  of  the  cells 
branched,  and  looking  like  myxoma  cells;  d,  spindle  cells  and  fibres, 
probably  developed  from  c. 

freely  used,  and,  when  all  bleeding  was  arrested,  a  solution  of 
chromic  acid  (gi. — "^i.)  was  applied  on  the  cottonwool  holder  to  the 
cavity.  Periodical  applications  of  carbolized  iodine  were  subse- 
quently made. 


A  fungoid  mass,  filling  the  fuudal  cavity,  was  removed  with  the  curette  and 


CANCER    OF  THE    UTERUS. 


561 


Siina'  knife,  from  a  |)ationt  aged  44,  and  cliromic  acid  was  applied.  (Sucli  a 
case  should  now  bo  dealt  with  by  paii-hystereetoniy.)  The  section  (Fig.  404) 
shows  the  microscopical  features  of  the  removed  mass.     I'lecurrcnce  after  a 


.-iii^^V 


>>^s 


Fig.  40."'. — Microscopical  SectionHof  Guowth  kemoved  by  Cdkette. 


9 

00  QC 


%5^^ 


Fig.  406. — Sections  showing  Glandular  Alveoli  lined  with  Colum.vah 
Epithelium — Matrix  of  Embryonic  Connective  Tissue  and  Blood- 
vessels IN  Section. 

[In  the  portion  figured  there  is  no  evidence  of  epithelial  proliferation  or  en- 
croachment into  the  surrounding  tissue ;  other  parts  of  the  sections,  how- 
ever, show  these  conditions — i.e.  an  approach  to  epithelioma.]  * 

period  of  quiescence  took  place,  and  the  same  treatment  was  again  adopted. 
The  disease  soon  involved  the  entire  cervix  and  the  vaginal  roof.  Death 
occurred  in  about  eighteen  months  from  the  date  of  the  curettage. 

*  Phineas  Abraham  furnished  the  pathological  report  on  these  sections. 

2  o 


562  DISEASES    OF    WOMEN. 

In  the  second  case  a  bleeding  mass  protruded  from  the  cervix  (patient  aged 
33).  The  section  (Fig.  405)  shows  the  nature  of  the  growth  removed.  There 
has  never  been  any  return  of  the  disease.     This  occuiTed  twenty  years  since. 

In  the  third  case  examination  revealed  a  mass  of  a  raspberry  appearance, 
bleeding  on  being  touched,  and  filling  the  cervical  canal.  There  has  been  no 
recurrence.     This  growth  was  removed  some  15  years  since.     (Fig.  406.) 

Origin — Local  or  Constitutional. — Most  distinguished  pathologists  have  been 
divided  in  opinion  as  to  whether  cancer  is  primarily  a  local  disease — one  of 
the  peculiar  characteristics  of  which  is  to  rapidly  invade  the  system  through 
the  blood  and  lymphatics — or  but  the  local  manifestation  of  a  constitutional 
or  general  blood  state. 

There  is  much  to  be  said  for  both  these  views.  It  is  a  common  occurrence 
to  find  cancer  in  persons  of  a.  robust  constitution  in  other  respects.  In  many, 
however,  it  is  certain  that  there  is  a  constitutional  vice  present  long  before 
the  malignant  tendency  manifests  itself,  and  the  apparent  evidence  of  the 
hereditary  tendency  in  some  cases  would  seem  to  justify  this  opinion.  There 
are  peculiarities  connected  with  the  malignant  tendency  in  some  organs,  as 
in  the  breast,  the  penis,  the  lip,  and  the  scrotum,  which  appear  strongly  to 
favour  its  local  origin.  On  this  interesting  question,  however,  we  cannot 
enter  here. 

Predisposing  Causes. — It  would  appear  from  the  statistics  of 
Simpson,  Kiwisch,  and  others,  that  in  over  one-third  of  all  cases  of 
cancer  the  uterus  is  the  organ  affected,  though  the  liability  to 
distant  metastases  is  not  very  great  if  we  except  the  omentum,  and 
this  occurs  principally  through  the  parametria.  We  may  regard 
as  the  most  frequent  of  the  predisposing  influences  in  the  causation 
of  cancer  of  the  uterus,  the  period  of  life,  the  consequences  of 
parturition,  and  mental  strain  and  worry.  The  possible  part 
played  by  laceration  of  the  cervix  has  already  been  noticed.  By 
some,  excessive  sexual  intercourse  is  believed  to  act  as  an  exciting 
cause,  yet,  as  Schroeder  remarks,  prostitutes  have  no  special  ten- 
dency to  cancer  of  the  uterus.  The  old  and  popular  belief  in  the 
hereditary  character  of  the  disease  i^  not  now  held  as  it  used  to  be. 
At  the  same  time  it  is  not  so  far  discredited  that  we  are  not 
influenced  by  an  unfavourable  family  history  and  evidence  of  the 
presence  of  the  disease  at  either  side  of  the  family  tree.  As  regards 
age,  the  statistics  of  Schroeder,  Gusserow,  Backer,  and  those  of  the 
Frauenklinik  at  Munich,  among  others,  are  sufficient  for  our  pur- 
pose,, covering,  as  they  do,  some  five  thousand  cases.  From  these 
it  is  evident  that  by  far  the  largest  proportion  occurs  shortly  before, 
during,  and  after  the  menopause,  and  that  it  is  more  frequently 
present  in  married  women  or  widows.  According  to  Coe,  four- 
fifths  of  the  recorded  cases  occur  in  patients  over  forty  years  of  age. 


CANCER    OF   THE    UTERUS. 


Among  the  earliest  cases  of  carcinoma  of  the  cervix  that  have 
been  recorded  are  those  at  2  years  (Rosenhein),  IG  years  (Schauta), 
17  (Glatter),  19  (Bieget  and  Eckhardt).  We  may,  therefore,  con- 
clude that  the  most  susceptible  years  to  cancerous  degeneration 
are  those  between  35  and  50.  Some  3  to  5  per  cent,  occur  between 
the  ages  of  20  and  30,  5  per  cent,  between  60  and  70,  and  from 
1  to  2  per  cent,  over  70.  Though  a  short  table,  that  of  Backer 
fairly  represents  the  periods  of  increase  and  diminution  according 
to  the  ages  at  which  cancer  occurs. 


21  to  25 : 

'ears 

of  age, 

14  cases 

1-98  per 

cent 

26  „  30  ' 

)) 

45 

6-38 

31  „  35 

V 

90 

12-76 

36  „  40 

134 

19-01 

41  „  45 

)> 

157 

22-27 

46  „  50 

127 

18-01 

51  „  55 

)) 

71 

10-07 

56  „  60 

11 

44 

...       6-24 

61  „  65 

11 

15 

2-12 

66  „  70 

11 

5 

0-71 

71  „  75 

11 

^fe^^i-r 

3 

,     '70.     ^„1, 

0-42 

k„„. 

Of  948  women  affected,  in  78  only  was  the  cancer  hereditary 
(Schrceder).  General  instances  of  sarcoma  in  children  under  one 
year  old  have  been  recorded — vide  Sarcoma. 

As  regards  the  location  of  the  disease,  statistics  show  that  the 
parts  most  frequently  affected  are  the  cervix  and  portio,  and  the 
direction  of  the  growth  more  frequently  towards  the  vagina  or 
parametrium,  less  so  to  the  bladder,  and  rarely  to  the  rectum. 
Multipara  are  more  frequently  affected  than  sterile  women.  The 
tendency  to  the  lateral  and  downward  spread  of  the  disease 
explains  the  frequent  inclusion  of  the  adnexa,  broad  ligaments, 
and  vagina. 


Carcinoma  Psammosum. 


For  the  accompanying  drawing  I  am  indebted  to  Heiuricli  Schmit.  The 
woman  was  operated  upon  in  October,  1898,  while  I  was  in  Vienna,  by 
Professor  Schauta.  The  operation  was  abdominal  hysterectomy,  and  the 
recovery  was  rapid.  The  uterus  was  about  twice  the  size  of  a  closed  fist. 
On  the  surface  there  were  several  myomata,  but  the  uterine  cavity  was  filled 
with  a  crumbling  mass,  which  proved  microscopically  to  be  a  carcinoma 
psammosum  of  the  body.  In  every  section  there  were  chalky  concretions, 
consequent  upon  the  transformation  of  the  epithelial  cells  of  the  tumour.  The 
primary  seat  of  the  disease  was  in  the  body  of  the  uterus,  but  niestastatic 


564 


DISEASES    OF   WOMEN. 


deposits  of  a  similar  character  were  found  in  both  tubes  and  ovaries.     Such 
cases  are  extremely  rare. 


Fig.  407. — Cakcinoma  Psammosum.     (Scumit.) 

Hitschmann*  asserts  that  metaplasis  from  cylindrical  epithelium 
into  squamous  occurs  frequently  in  carcinoma  of  the  body,  and  that 
the  glandular  epithelium  passes  into  the  squamous  form.  Squamous 
epithelium  may  thus  undei"go  corneous  metamorphosis,  and  when 
hyaline  degeneration  takes  place,  the  change  into  carcinoma  psam- 
momum  occurs  (Fig.  407). 

I  have  only  personally  followed  the  stages  of  one  case  in  which  pre-existing 
*  Archiv.f.  Gyn.,  bd.  lxix.,"heft  3,  p.  628,  1903. 


CANCER   OF   THE    UTERUS.  565 

cervioitis,  whether  catarrlial  or  granular,  gradnally  passed  into  malignant 
disease  of  the  utcrns.  I  have  frequently  met  with  cases  in  which  I  liave  been 
told  that  this  has  occurred,  but  the  diagnosis  of  malignancy  has  been  clear  on 
ray  seeing  the  patient.  The  existence  of  follicular  hypertrophy  of  the  neck 
in  multiparse,  and  its  persistence  after  the  menopause,  is  the  condition  I 
specially  fear  among  the  premonitory  or  predisposing  conditions.  Such  folli- 
cular conditions  I  have  seen  terminate  in  carcinoma.  The  presence  of 
lacerations  of  the  cervix  in  some  cases  may  be  fairh'  looked  on  as  a  mere  co- 
incidence of  the  multiparous  uterus;  the  strongest  pre-disposing  cause 
unquestionably  is  repeated  pregnancies.  Race  seems  to  exert  considerable 
influence,  judging  from  the  comparative  but  by  no  means  complete  immunity 
of  the  negro  races. 

Examination  of  the  Uterus  after  Pregnancy. 

American  authorities  insist  on  the  importance  of  making  an  examination 
periodicall}^  after  confinement,  so  as  to  note  the  appearance  of  any  lesions 
that  may  have  followed  labour.  Kelly  advises  that  every  woman  over  thirty- 
live  years  of  age  with  a  laceration  should  be  yearly  examined  with  this  object, 
and  Stone  advises  that  all  women  in  whom  we  have  reason  to  suspect, 
through  heredity  or  otherwise,  the  occun*ence  of  cancer  should  likewise  be 
examined.  [This  subject  has  already  been  referred  to  in  the  chapter  on  lace- 
ration of  the  cervix.] 

Clinical  Differentiation. — The  clinical  distinction  of  cancroid  and 
carcinoma  may  be  found  in  the  comparatively  slow  progress  of  the 


'^_ 


!ii» 


Fig.  408. — Surface  of  Cervix,  showixg  Epithelial  Ixgrowixg.    (Author.; 
(High  amputation — death  fifteen  months  subsequently.*) 

*  '  The  growth  is  a  typical  example  of  epithelioma,  aDastomosing  prolongations, 


56fi  DISEASES   OF   WOMEN. 

cancroid  or  epithelioma,  the  more  superficial  situation  of  the  latter 
disease  in  the  early  stage,  and  its  spreading  character.  Carcinoma 
is  more  rapid  in  its  progress,  and  affects  by  metastasis  the  pelvic 
and  lumbar  glands  and  distant  organs,  as  the  lungs  and  liver.  The 
'  rodent,'  or  '  corroding,'  ulcer  of  Clark  is  a  rare  form  of  malignant 
ulceration.  Extensive  ulceration  is  the  main  feature,  often  con- 
tinuing   for  years    before    death   occurs.     The    'cauliflower    excre- 


0    V  ' 


Fig.  409. — Teue  '  Nest.'        Fig.  -110. — Fasciculated  Con- 
(Same  specimen.)  ^^^^^  Tissue. 

a.  Fig.  408.  (Same  specimen.) 

scence,'  or  malignant  vegetating  papilloma,  has  been  already  briefly 
referred  to.  While  the  differentiation,  clinically,  of  the  different 
forms  of  epithelial  cancer  becomes  almost  impossible  when  the 
disease  has  lasted  for  any  time,  and  ulceration  has  extended  widely 
and  deeply,  the  distinctive  characters  of  scirrhus,  in  its  slow  progress, 
the  hard  and  nodular  nature  of  the  growth,  and  the  small  discharge 
that  attends  its  earlier  stages,  are  quite  apparent. 

"  tubular  "  and  irregular,  extending  from  the  surface  epithelium  of  the  os  into 
the  subjacent  tissue  (Fig.  408).  In  several  of  these  epithelial  encroach- 
ments, centripetal  collections  of  young  cells — the  so-called  "nests" — are  formed 
(Fig.  410),  or  in  process  of  forming.  In  some  of  these  the  central  (newest)  cells 
are  very  large,  succulent,  and  rapidly  dividing.  In  the  tissues — fibrous  and 
muscular — which  surround  the  heterogeneous  epithelial  ingrowths,  the  usual 
small-celled  inflammatory  infiltration  characteristic  of  these  malignant  growths 
is  evident  in  several  places.'     (Abraham.) 


CHAPTER  XXXI. 
CANCER  OF  THE  UTERUS  (continued). 

Cancer  of  the  Portio  Vaginalis,  Cervix,  and  Body— Sarcoma. 

Symptoms  and  Physical  Signs. — Cancer  of  the  portio  and  cervix 
uteri  has,  as  a  rule,  four  symptoms,  so  characteristic  that  it  is  well 
to  group  these  in  the  first  place  together.     They  are — 

Pain  ; 

Haemorrhage  ; 
Fcetid  discharge ; 
General  cachexia. 

The  first  and  ever-to-be-remembered  clinical  fact  connected  with 
the  symptomatology  of  malignant  disease  of  the  uterus,  which  it  is 
right  for  the  pz'actitioner  to  keep  always  in  mind,  is,  that  cancer  of  the 
womb,  whether  of  cervix  or  hody,  may  exist  for  a  considerable  time,  and 
many  or  all  of  its  characteristic  symptoms  remain  in  abeyance.  It  is 
not  uncommon  to  see  extensive  inoperable  carcinoma  of  the  cervix 
where  the  first  thing  complained  of  is  haemorrhage.  This  leads  to 
an  examination,  and  the  cancer  is  then  discovered. 

Cases  are  constantly  seen  in  which  no  pain  is  complained  of,  and 
where  the  patients  first  seek  advice  when  it  is  too  late  to  propose 
any  operative  measure,  the  peri-uterine  structures  and  Douglas' 
pouch  being  involved.  In  the  same  way  some  patients  suffer  from 
what  they  believe  to  Ido  leucorrhoeal  discharge.  They  pay  little 
attention  to  this,  treating  it  as  '  whites,'  and  seek  no  advice,  or 
they  are  not  examined  until  the  cervical  tissues  are  deeply  fissured 
and  the  malignant  change  has  commenced. 

Pain. — The  pain  of  cancer  is  generally  of  a  burning  or  lancinating 
natui'e,  and  is  especially  felt  at  night.  Occasionally  coitus  is  painful 
in  the  early  stages  of  the  disease,  and  the  uterus  is  sensitive.  At 
other  times  intercourse  gives  rise  to  no  pain.  As  the  disease  spreads 
to  the  vagina  the  pain  is  increased,  and  is  more  aggravated,  being 
felt  with  the  movements  of  the  bladder  and  rectum,  and  preventing 
sleep.  It  is  often  concentrated  in  the  sacral  region,  and  travels  in 
the  course  of  the  sacral  nerves,  and  extends  down  the  backs  of  the 


568 


DISEASES   OF   WOMEN. 


thighs.     Later  still,  it  becomes  intolerable,  and  the  patient  craves 
for  morphia  and  sedative  injections. 

Hsemorrhage. — In  the  earlier  stages  of  the  disease,  this  is  the  most 
frequent  symptom.  At  first,  it  may  be  simple  menorrhagia.  The 
menstrual  flow  is  increased.  Perhaps  there  is  some  slight  bleeding 
with  intercourse.  After  a  time  it  becomes  metrorrhagic  in  character, 
and  there  is  either  a  constant  or  periodic  discharge.  We  may  be 
suspicious  of  malignancy  should  the  cervix  bleed  readily  on  exami- 


FiG.  411. — Cancer  eating  away  the  Lower  Half  of  the  Uterus,  and 

PERFORATING   INTO    THE    BlADDER.       (EoBERT    BaRNES.) 

Half-size;  St.  Thomas's  Museum. 

nation,  and  when  there  is  no  erosion  to  explain  this ;  also,  if  the 
cervix  be  congested,  the  veins  somewhat  engorged,  and  the  lips  of 
the  OS  have  a  glazed  and  semi-everted  look.  The  half -watery, 
partly  bloody,  somewhat  foetid  and  erratic  nature  of  the  discharge, 
in  the  earlier  stages  of  malignant  disease,  is  always  sufficient  in  itself 
to  arouse  suspicion.  Still,  the  tendency  to  menorrhagia  may  be  the 
symptom  most  urgently  demanding  attention,  and  there  is  no  rule 
more  absolute  in  gynaecology  than  this — in  ■  all  cases  of  ^persistent 
menorrhagia  or  metrorrhagia  inquire  carefully  into  its  cause,  and 
accept  no  responsibility  for  the  consequences  unless  a  vaginal  examina- 
tion be  permitted. 


CANCEB    OF  THE    UTERUS. 


560 


Foetid  Discharge.— It  may  be  laid  down  as  a  safe  rule  in  gynaico- 
logical  practice — polypus,  and  conditions  arising  out  of  pregnancy 
being  excluded — that  if  there  be  haamorrhage  with  fcetor,  we  should 
suspect  the  presence  of  malignant  disease.  The  fcietor  arising  from 
JbJ»«  putrescence  of  the  disintegrating  and  necrosed  uterine  tissue  we 
may  look  on  as  the  most  invariable  accompaniment  of  cancer  of  the 
womb.  The  patient  herself  soon  becomes  aware  of  the  odour.  In 
the  final  stages  of  the  disease,  if  not  controlled,  it  pervades  her 
clothes,  and  the  room  in  which  she  is  confined.  This  fcetor,  how- 
ever, is  not  by  any  means  an  invariable  accompaniment  ;  especially 
in  cases  where  haemorrhage  is  present,  and  the  necrosed  particles  are 
washed  away  with  the  discharge  of  blood. 

Complication  of  the  Urinary  Organs, — Frequently  there  are  most  distressing 


Fig.  41*2. — Double  Htdro-teeter  due  to  adtaxced  Caxcee  of  the 
Utekus.     (H.  Kelly.)* 

Adhesions  connected  the  uterus  to  the  bladder,  also  the  ureters,  and  there  was 
cicatricial  tissue  between  the  latter  and  about  the  kidneys. 


See  also  chapter  on  Ureters. 


570  DISEASES   OF   WOMEN. 

renal  and  vesical  symptoms,  which  are  due  to  involvement  of  the  ureters  and 
bladder  in  the  disease.  The  former  may  be  ulcerated  or  distended  through 
obstruction  at  their  lower  ends.  McClintock  was  the  first  who  drew  attention 
to  the  occasional  termination  of  the  disease  by  ursemic  poisoning  from  nephritic 
changes.  Such  renal  changes  consist,  according  to  Strauss  and  Germont,  in 
alterations  in  the  papilla  and  the  pyramids.  The  former  are  flattened  and 
irregular,  while  later  on  the  secretory  tissue  of  the  kidney  is  destroyed,  its 
place  being  taken  by  a  fibrous  membrane.  If  the  bladder  be  engaged  in  the 
disease,  the  extension  of  mischief  to  the  ureter  and  kidney  is  generally  of  a 
rapid  character,  and  is  rarely  followed  by  pyonephritis,  the  renal  consequences 
being  due  rather  to  the  obstruction  of  the  ureters  with  resulting  hydrops 
ureteri. 

General  Cachexia. —  Sooner  or  later  the  involvement  of  the  system 
in  the  affection,  brought  about  by  the  pain,  sleeplessness,  anxiety, 
pelvic  visceral  trouble,  loss  of  blood,  and  constant  discharge, 
manifests  itself.  There  is  general  emaciation,  and  the  face  has  the 
anxious,  painful,  and  worn  expression  common  to  cancer  elsewhere. 
In  protracted  cases  there  is  a  discoloured,  almost  icteric,  tint. 

Other  Physical  Signs. — As  uterine  cancer  progresses,  the  general 
clinical  features  will  depend  to  a  great  extent  upon  the  degree  to 
which  other  parts  or  organs  are  involved,  and  the  accidental  com- 
plications that  may  arise.  The  rectum  and  bladder,  the  ureters,  the 
pelvic  and  general  peritoneum,  the  pelvic  veins,  and  lymphatics, 
may  each  in  turn  be  attacked.  Septicaemia,  peritonitis,  phlebitis, 
or  pneumonia  may  follow. 

In  the  early  stage  there  is  not  much  to  rely  on  as  distinctive 
of  malignancy.  The  hardness  of  the  cervix,  or  the  increased 
sensitiveness  and  slight  haemorrhage,  are  not  in  themselves  sufficient 
to  justify  any  positive  decision.  But  the  local  conditions  after  a 
time  leave  little  room  for  doubt.  The  soft  and  friable  cervix, 
with  the  everted  and  hardened  rim  of  cervical  tissue ;  the  proneness 
to  hfemorrhage  even  on  a  slight  examination  with  the  finger ;  the 
detection  of  foetor  ;  the  fixed  uterus ;  its  ragged  and  excavated 
appearance,  or  the  presence  of  a  vegetating,  fungus-like  and  bleed- 
ing mass,  seen  with  the  speculum,  are  not,  with  any  exercise  of  care, 
to  be  mistaken  for  laceration,  erosion,  areolar  hyperplasia,  or  slough- 
ing polypus.  If  the  bladder  and  rectum  be  involved,  the  distress 
becomes  great,  and  the  woman's  release  from  suffering  and  misery 
is  only  to  be  found  in  death. 

Among  the  later  symptoms  of  carcinoma  of  the  uterus  are  those 
due  to  involvement  of  the  rectum.  Pain  and  tenesmus  are  not 
infrequent  attendants,  and  there  is  often  a  certain  degree  of  proctitis 


PLATE   XLIJ. 


Myoma  complicated  with  Carcixoma.     (Author.) 

The  fibro-myoma  was  the  size  of  a  foetal  skull  at  term.  It  was  removed  from  a 
spinster,  aged  58,  by  vaginal  hysterectomy.  Patlwlo(jiecd  Report :  The  speci- 
men consisted  of  three  portions  ;  the  largest  was  an  oval  intramural  iibroid, 
5  ins.  in  its  chief  diameter,  projecting  from  the  back  of  the  uterus  near  the 
fundus.  The  lower  segment  of  the  uterus  was  invaded  by  a  soft  white 
growth,  a  columnar-celled  carcinoma,  with  solid  branching  columns  of 
epithelium.  Below  this  was  a  small  fibroid  distinct  from  the  carcinomatous 
portion,  and  not  infiltrated  by  it.  The  third  part  consisted  of  the  cervix 
uteri,  and  adjacent  portions  of  the  vagina.  The  os  uteri,  the  internal 
surface  of  the  cervix  uteri,  as  far  as  the  internal  os,  were  normal,  though 
there  was  much  inflammatory  infiltration  between  the  bundles  of  muscle 
fibres.  The  patient  made  a  good  recovery  from  the  operation,  survived 
twelve  months,  and  died,  as  I  learned,  from  some  acute  attack  of  bowel 
obstruction,  doubtless  of  a  malignant  nature.     (See  pp.  iOG  et  seq.) 

[To  face  p.  570. 


CANCEB    OF   TEE    UTERUS.  571 


present.  These  symptoms  are  associated  with  constipation  and 
difficulty  in  defecation.  They  may  be  present  long  before  the  coats 
of  the  rectum  are  invaded  to  such  an  extent  as  to  produce  a  fistula. 

When  the  disease  has  extended  so  far  as  to  include  the  lai'ger 
pelvic  veins,  these  are  compressed,  or  the  infiltration  blocks  their 
lumen  so  that  thrombosis  follows,  and  an  oedematous  condition  of 
the  lower  extremities  is  a  consequence.  As  pointed  out  by  Cumston,* 
death  does  not  frequently  follow  from  sepsis,  nor  from  hasmorrhage. 
This  is  due  to  the  incapacity  of  the  lymphatic  vessels  to  absorb 
the  septic  products  within  the  area  of  the  disease,  and  the  blockage 
of  the  infiltration  thrombosis  in  the  neoplastic  area.  The  affected 
parts  may  be  said  to  be  encapsulated.  Death  from  peritonitis  is 
not  uncommon,  from  extension  of  the  malignant  invasion  to  the 
peritoneal  surfaces  of  the  bowel  and  parietes. 

In  all  instances  where,  early  in  the  disease,  a  doubt  exists  between 
a  benign  and  malignant  condition,  the  microscope  should  be  brought 
to  our  aid,  and  a  small  portion  removed  and  carefully  prepared  for 
examination.  When  we  suspect  malignant  disease  of  the  body  of 
the  uterus,  where  the  curette  is  used,  not  only  should  we  get  a 
portion  removed  rather  deeply  and  extending  into  the  parenchyma, 
but  of  equal  importance  is  it  to  get  particles  from  two  or  three 
different  situations.  The  typical  appearances  of  the  stroma,  alveolar 
spaces,  and  nucleated  cell,  will  enable  us  fairly  to  decide  as  to  the 
malignancy  or  otherwise  of  a  growth.  Yet  this  test,  should  the 
result  be  a  negative  one,  must  ever  be  looked  on  as  only  one  of  the 
several  pi'oofs  of  malignancy,  as  it  is  often  difficult  to  obtain  sufficient 
tissue  to  enable  us  to  exclude  the  possibility  of  malignant  infiltration. 

Differential  Diagnosis. — There  are  some  pathological  conditions 
of  the  cervix  and  portio  that  frequently  cause  doubt  as  to  the  can- 
cerous nature  of  the  affection.     These  are — 

Laceration,  with  erosion  and  granular  degeneration  of  the  cervix. 

Benign  papillomatous  growths. 

Hyperplasia  of  cervix.  Sarcoma. 

Syphilitic  ulceration.  Follicular  hypertrophy. 

Polypus  of  the  cervix.  Tntra-uterine  sloughing  fibroid. 

Our  diagnosis  must  depend  on  these  clinical  facts : — 

1.  The  comparatively  rapid  progress  of  the  symptoms. 

2.  The  absence  of  other  proofs  of  syphilis. 

3.  The  age  of  the  patient,  and  the  family  history. 

*  Ann.  Gyn.  and  Fed.,  March,  1902. 


572  DISEASES  OF   WOMEN. 

4.  The  presence  of   the   characteristic   symptoms    and    signs   of 

malignancy  :  especially — pain,  haemorrhage,  ichorous  leucor- 
rhcea,  foetor,  rectal  distress,  and  pain  on  defaecation. 

5.  Immobility  of  the  mucous  membrane  on  the  subjacent  tissue 

— early  in  the  disease  (Waldeyer) — and  fixation  of  the  uterus. 
Later  on,  the  resistance  of  the  cervical  canal  to  the  action  of 
a  sponge-tent  (Spiegelberg). 

6.  The  involvement  of  the  adjacent  vaginal  "wall. 

7.  Persistency  of  the  local  signs  notwithstanding  treatment. 

8.  The  appearance  of  the  patient,   and    evidence   of  increasing 

cachexia, 

9.  The  condition  of  the  cervix,  as  felt  with  the  finger  and  seen 

through  the  speculum. 

10.  Evidence  of  metastasis,  and  of  malignant  growths  elsewhere. 

11.  The  microscopic  appearances. 

Early  Local  Signs. — Stratz  has  drawn  special  attention. to  the 
colour  of  the  excoriated  surface  early  in  the  disease  : — 

(a)  A  yellowish-red  granular  surface ; 

(&)   A  slight  yellowish  discoloration  ; 

(c)  Yellowish-white,  glistening,  granular  bodies  over  the  surface 
of  the  cer\T.x. 

I  have  frequently  noticed  this  discoloration  in  cases  of  threaten- 
ing cancer,  as  also  the  dark-red  swollen  proliferation  of  one  lip, 
pretty  sharply  defined  and  somewhat  elevated,  described  by  Stratz. 
The  vaginal  mucous  membrane  appears  also  to  partake  of  this  process 
of  discoloration  and  infiltration ;  it  assumes  a  yellowish  or  mottled 
look,  and  has  rather  a  smooth  leather-like  surface  and  feel. 

Carcinoma  of  tlie  Body  of  the  Uterus. — There  are  important 
reasons  for  studying  the  signs  of  cancer  of  the  body  of  the  uterus 
apart  from  that  of  the  cervix.    We  may  epitomize  these  as  follows  : — 

1.  It  is  not  so  common  as  cancer  of  the  cervix. 

2.  It  is  a  disease  of  more  advanced  life,  generally  occurring  during 

or  after  the  menopause. 

3.  It  is  found  more  frequently  in  nuUiparous  women. 

4.  Histologically  it  is  more  allied  to  sarcoma  or  adenoma. 

5.  The  symptoms  are  more  obscure  than  in  malignant  disease  of 

the  cervix. 

6.  The  body  of  the  uterus  is  the  part  affected,  the  cervix  being 

comparatively  free  :  the  body  may  be  enlarged,  or  hollowed 
out,  and  filled  with  the  cancerous  mass :  or  the  parenchyma 
may  be  the  part  "principally  involved. 


X 


< 


PLATE   XLIV. 


CUEEETTINGS    FKOM    FUNDXJS    EE5I0VED    BEPOKE    OPEEATION. 

[To/«ce  p.  578. 


CANCER    OF  THE    UTERUS. 


573 


Abel  first  proved  that  the  corporeal  endometrium  is  much  more  frequently 
affected  in  cervical  car- 
cinoma than  had  been 
believed,  and  he  found 
that  the  change  more 
frequently  took  on  the 
form  of  round  or  spindle- 
celled  sarcoma. 

Cancer  of  the  Body. 
— Commencing  either 
in    the    epithelium   of 
the  uterine  glands,  in 
the  parenchyma,  or  in 
the   connective  tissue, 
general  thickening  of 
the  mucous  membrane 
with    disintegration 
and  discharge  follows, 
or    scattered    nodular   Fig.   41 8.- Cancer   of    the    Body   assuming    the 
deposits    are    formed,       Appearance  op  a    Submucous  Fibroid.      (Euge 
or  a  diffused  infiltra-       ^^^  ^'^^i^-) 
tion  occurs.     Perforation 
of   the   uterus   may  ulti- 
mately   follow,    and     an 

opening   into   either    the  -— ^«^-w.'-.i>-.        .^   —      "^ 

bowel  or  bladder  result, 
or  this  may  be  prevented 
by  adhesions. 

Diagnosis. — When  any 
patient,  over  forty  years 
of  age,  presents  herself 
complaining  of  pain,  in- 
termittent haemorrhage, 
foetid  discharge  of  a 
watery  nature,  at  times 
coloured,  and  especially 
if  these  symptoms  make 
their  appearance  after  the 
menopause,  and  where 
menstruation  has  ceased 
for  some  time,  cancer  of 
the    body    of    the    womb 


P'iG.  414, — Carcinoma  op  the  Cervix. 

(Jessett.) 

Drawing  from  specimen  in  Cancer  Hospital 
Museum. 


574 


DISEASES   OF    WOMEN. 


should  be  suspected.  If  on  digital  examination  the  cervix  be 
found  healthy  and  the  fundus  enlarged,  and  that  with  the  uterine 
probe  some  foul-smelling  and  discoloured  discharge  can  be  wiped 
from  the  cervix,  the  latter  should  be  dilated,  the  cavity  of  the 
uterus  explored,  and  the  spoon  curette  used  to  remove  two  or  three 
portions  of  the  endometrium  and  subjacent  tissue  for  microscopical 
examination.  Such  microscopical  examination  will  enable  the  surgeon 
to  decide  as  between  cancer,  adenoma,  a  sloughing  intra-uterine  fibroid, 


Fig.  415. — Cakcinoma  of  the  Body  of  the  Uterus.    (Jessett.) 
Drawing  from  specimen  in  Cancer  Hospital  Museum. 

polypus,  ^fungous  endometritis,^  s^ndi products  of  conception.  Should  the 
symptoms  arise  during  the  child-bearing  period  of  life,  the  probability 
of  these  latter  being  the  cause  must  not  be  lost  sight  of.  If  the 
cavity  of  the  uterus  be  carefully  explored  and  found  enlarged,  or 
any  soft  mass  which  bleeds  readily  and  imparts  a  foul  odour  to  the 
finger  be  protruding  into  it,  and  if,  in  addition,  the  uterus  be  fixed  by" 
adhesion,  and  there  be  accompanying  cachexia,  even  without  micro- 
scopical examination  the  opinion  will  be  on  the  side  of  malignancy. 


CANCER    OF  THE    UTERUS.  575 

The  microscope  will  dissipate  any  doubt  that  remains,  and  this  should 
altoays  be  made  the  final  test. 

Differentiation  of  Fungous  Endometritis. — Heitzmann  (New 
York),  conniienting  on  the  fact  that  it  is  extremely  difficult  to 
diagnose  accurately  such  conditions  as  polypoid  growths,  sarcoma 
and  papilloma  of  the  mucosa,  adenoma,: and  carcinoma,  frum  fungous 
endometritis,  from  repeated  microscopical  examinations  draws  these 
distinctions : — 

'  Endometritis  Fungosa  is  characterized  under  the  microscope  by  the 
presence  of  a  varying  number  of  tubular  utricular  glands,  the  epithelia  of 
which  are  columnar,  ciliated,  but  always  unbroken.  The  connective  tissue 
between  the  tubular  glands  may  be  crowded  with  lymph-corpuscles,  exhibiting 
a  hyperplasia  of  the  adenoid  or  Ij'mph-tissue  of  the  uterine  mucosa,  or  the 
insterstitial  tissue  between  the  tubides  is  found  to  be  myxomatous,  or  even 
fibrous,  in  nature.  These  difl'erences  probably  depend  on  the  age  of  the 
patient. 

'  Polypoid  Tumours  consist  of  myxomatous  tissue,  and  are  properly  termed 
mj'xomata;  or  if  bundles  of  a  delicate  fibrous  connective  tissue  enter  the 
structure,  fibro-myxomata.  Glandular  formations  in  such  tumom's  are,  as  a 
rule,  scant  or  absent ;  they  not  infrequently  contain  cysts. 

'  Sarcoma — especially  in  its  earlier  stages — occurs  under  the  cUnical  symp- 
toms of  fungous  endometritis,  mostly  diffused  ;  and  the  correct  diagnosis  can 
be  made  with  the  microscope  only  when  the  epithelia  of  the  tubular  glands, 
either  the  original  or  newly-formed,  are  destroyed  b}'  the  sarcomatous  growth. 

'In  sarcoma  the  epitheha  of  the  utricidar  glands  are  transformed  into 
sarcoma  corpuscles,  either  directly  by  a  process  of  division,  or  through  the 
intervening  stage  of  a  coalescence  into  granular  protoplasmic  masses. 

'  Papilloma  of  the  Uterine  Mucosa  does  occur  in  exactly  the  same  way  as 
on  the  mucosa  of  the  urinary  bladder.  This  form  of  tumour  is  extremely 
rare. 

'  Adenoma  is  a  rare  form  of  tumour,  sometimes  appearuig  under  the  chnical 
features  of  fungous  endometritis.  It  consists  of  a  new  growth  of  the  utricular 
glands  in  a  plexiform  arrangement  with  narrow  calibres.  The  connective 
tissue  between  the  epithelial  formations  is  fibrous  and  scanty. 

'  Cancer  appears  in  the  uterine  mucosa  in  the  form  of  epithelioma  and 
medidlary  cancer.  The  utricular  glands  are  not  directly  formed  into  cancer 
nests,  but  their  epithelia  first  breaks  up  into  medullary  coipuscles,  or  into  larger 
masses  of  protoplasm,  from  which  the  cancer  epithelia  arise.' 

SARCOMA. 

Compared  with  carcinoma  of  the  cervix,  sarcoma  is  comparatively 
rare,  probably  not  one  case  in  twenty  of  malignant  disease  of  the 
internal  genitalia  proving  to  be  of  the  sarcomatous  nature.  In  the 
body  of  the  uterus,  however,  it  is  relatively  more  frequent,  about 


576  DISEASES   OF   WOMEN. 

half  of  the  cases  of  malignant  disease  of  the  corpus  being  sarcoma. 
It  is  recognized,  pathologically  and  clinically,  as  occurring  in  two 
principal  forms,  according  to  the  structure  in  which  it  arises.  This 
may  be  either  in  the  parenchyma  of  the  uterus  or  its  mucous  membrane 
—from  the  latter  rarely.  In  the  former  case  it  is  of  a  more  isolated 
character,  and  the  nature  of  the  growth  will  depend  upon  its  suh- 
peritoneal,  interstitial,  or  submucous  situation.  The  submucous  and 
subperitoneal  project  on  the  surface  or  into  the  cavity  of  the  uterus 
in  the  direction  of  least  resista,nce,  while  the  interstitial  are  dis- 
seminated in  the  tissue  of  the  wall  of  the  body  of  the  uterus.  Such 
submucous  sarcomata  occasionally  have  had  an  origin  in  a  polypus. 
Those  sarcomatous  growths  which  spring  from  the  connective  tissue 
of  the  endometrium  usually  take  the  form  of  papillary  growths  upon 
its  surface,  frequently,  however,  infiltrating  the  mucous  membrane 
and  involving  the  uterine  parietes  as  far  as  its  peritoneal  coat. 
Thus,  certain  soft  sarcomata  may  become  attached  to  the  adjacent 
viscera,  or  project  as  soft  fungus-like  masses  into  the  uterine  cavity. 
There  is  a  feature  in  regard  to  sarcoma  of  the  female  genitalia  which 
must  be  remembered.  It  often  takes  on  the  pedunculated  form, 
both  in  the  uterus  and  in  the  vagina.  It  is  not  often  of  the  irre- 
gular granular  type  which  is  assumed  by  carcinoma.  That  a 
fibromyomatous  tumour  may,  as  we  have  seen,  degenerate  into  a 
sarcoma  is  now  an  acknowledged  fact.  In  a  multiparous  woman 
at  the  period  of  the  menopause  such  a  change  is  more  likely  to 
occur.  From  what  has  been  already  stated  of  the  generation  of 
cancer  epithelia  in  connective  tissue,  we  are  prepared  for  the 
actual  development  of  sarcoma  from  the  same  elements. 

Eoger  Williams  *  classifies  the  various  uterine  sarcomata  under  five  heads 
— (1)  Infantile ;  (2)  grape-like,  or  botryoidal ;  (3)  sarcoma  of  the  mucosa ; 
(4)  sarcoma  of  the  parenchyma ;  (5)  deciduoma  malignmn.  Showing  the 
comparative  rarity  of  sarcoma,  he  mentions  the  fact  that,  of  6754  cases  of 
uterine  neoplasms,  only  ten  were  instances  of  this.  As  I  have  said,  however, 
this  must  be  regarded  as  far  too  low  an  estimate. 

Ages — Sarcoma  ia  Children. — Some  interesting  cases  of  children  affected 
by  sarcoma  have  been  recorded,  one  at  seven  months  old,  and  at  nine  months 
utero-vaginal  extirpation  by  the  sacral  way  was  carried  out,  the  child  making 
a  good  recovery  (Hollander).  In  C.  T.  Smith's  case,  the  child  was  three 
years  and  nine  months  old.  It  was  found  to  be  a  round  cell  sarcoma. 
Other  cases  are  recorded  at  four  months  (Ahfeld),  thirteen  months  (Farns- 
worth),  and  two  years  (Pick). 

WilHams  considers  that  many  of  the  malignant  tumours  of  infancy  and 

*  Brit.  Gijn.  Jour.,  May,  1897. 


CANCEn    OF   THE    FTERUS.  oil 

early  life  are  wrongly  named  cancerous  from  the  epithelial  elements  they  con- 
tain. They  are  in  reality  sarcomata.  The  grape-like  pedunculated  masses 
which  resemble  hydatid  moles,  and  are  soft  and  easily  detachable,  he  regards 
as  highly  malignant,  being  of  heterotopic  constitution — striped  muscle,  cartil- 
age, bone  and  epithelial  elements,  '  sequestrated  from  the  matrix  of  adjacent 
tissues  during  early  embryonic  life.' 

Such  growths  are  in  some  instances  papillary,  or  of  a  compound  sarco- 
matous character  ('  adeno-myxoma-sarcoma,'  '  myo-sarcoma-strio-cellulaire,' 
'myxoma enchoiidromatodes arborcscons,'  'fibroma papilkre cartilagiuescens'). 
The  commonest  forms  of  uterine  sarcoma  Williams  considers  to  be  those  of 
the  mucosa,  and  it  is  important  to  note  that  in  the  sarcomata  of  children,  as 
in  those  of  the  mucosa,  there  is  in  many  cases  a  production  of  numerous  softish 
round  polypoid  bosses,  and  in  young  patients  sarcomata  may  present  them- 
selves as  polypoid  tumours  springing  from  the  mferior  segment  of  the  uterus. 
Further,  the  infiltration  may,  as  in  the  case  reported  by  Simpson,  spread 
along  the  Fallopian  tubes  to  their  fimbriated  extremities.  Mucosal  sarcomata 
assume  a  large  size  in  the  fundus  uteri,  otherwise  they  are  apt  to  become 
poh'poid.  They  are  rich  in  blood  vessels,  and  consist  mainly  of  small  round 
spindle  cells,  held  together  by  a  scantj^  fibrous  matrix.  Eecurrence  and 
dissemination  are  apt  to  occur.  Glandular  elements,  as  reported  by  Kay  and 
Schmit,  are  sometimes  intermixed  with  the  sarcomatous  new  fomaation ; 
and  other  authorities,  as  Johnston  and  Hackeling,  have  recorded  the  same 
intermixture.  Parenchymatous  sarcoma  is,  as  a  rule,  more  circumscribed 
than  the  other  varieties,  and  may  put  on  the  telangiectasic  type  (Aslanain)  ; 
and  Webster  has  recorded  a  case  of  angio-sarcoma,  a  unilocular  blood  cyst  of 
the  uterine  wall,  in  a  patient  aged  fifty -three.  I  have  already  alluded  to  the 
transition  of  fibromyomata  into  sarcomata  (Virchow,  Eokitansky,  Schrceder). 

The  sarcomata  maj^,  however,  also  arise  from  the  parenchymatous  elements, 
particularly  its  peri- vascular  and  lymphatic.  Williams  says, '  In  the  structure 
of  these  sarcomata  round  and  spindle  cell  forms  predominate,  but  myeloid 
elements  have  often  been  noticed.  Fibrous  tissue,  organic  muscle  cells,  blood- 
vessels, and  lymphatics  are  also  among  their  usual  constituents.  Myomatous 
and  oedematous  modifications  are  fairly  common.  In  the  soft,  shiny,  gi'ape- 
like,  easily  detachable  masses  of  the  neoplasm  we  maj'  recognize  the  racemose 
sarcomata,  but  the  microscope  alone  must  be  the  court  of  appeal  in  most  cases.' 

Symptomatology. — If  we  contrast  the  symptoms  of  the  fibre- 
sarcomata  with  those  attendant  upon  the  diffuse  variety,  we  find 
that  haemorrhage  is  present  in  both,  perhaps  more  profuse  in  the 
latter.  Semi-sanious  watery  discharges  periodically  occur  in  the 
two,  but  when  the  disease  attacks  the  mucous  membrane  particles 
of  necrotic  tissue  are  washed  away  by  the  discharge,  and  are  found 
in  it.  Severe  pain  accompanies  both  the  parenchymatous  and  sub- 
mucous forms.  That  of  the  interstitial  growth,  however,  is  more 
periodical,  of  an  expulsive,  'bearing-down  '  character,  and  associated 
with  ha3morrhage.  Such  pains  and  erratic  discharges  are  conse- 
quently apt  to  be,  and,  as  a  matter  of  fact,  often  are,  interpreted  as 

2  p 


578  DISEASES   OF    WOMEK. 


menorrhagic  or  metrorrhagic  losses  associated  with  the  menopause. 
There  is  this  striking  difference  between  the  two  types  of  disease  : 
in  the  interstitial  form  the  uterus  is  greatly  enlarged,  and  frequently 
its  canal  is  so  dilated  that  we  may  explore  and  reach  the  intra- 
uterine growths  with  the  finger.  In  the  diifuse  variety,  on  the 
other  hand,  though  the  uterus  is  increased  in  size,  and  possibly  im- 
movable, there  is  no  defined  tumour  felt  in  it  from  without.  Other 
symptoms  in  each  case  will  depend  upon  the  rapidity  of  the  extension 
of  the  disease,  and  the  degree  of  involvement  of  neighbouring  parts 
in  the  pelvis,  though  more  remote  organs,  such  as  the  lungs  and 
liver,  may  be  affected  by  metastasis.  The  ultimate  fatal  issue  does 
not  differ  from  the  corresponding  termination  of  a  case  of  diffuse 
carcinoma  of  the  uterus,  when  extension  has  taken  place  to  the 
structures  surrounding  it.  Indeed,  the  course  and  progress  of  the 
two  diseases  is  so  alike  that  it  is  often  impossible  to  distinguish 
them.  Microscopic  examination  of  portions  of  growth  removed  by 
the  curette  or  finger-nail  is  the  only  means  of  arriving  at  a  correct 
conclusion.  There  is  in  sarcoma,  especially  in  its  later  stages,  the 
same  cachetic  condition  that  we  have  in  carcinoma.  On  exami- 
nation of  a  uterus,  the  haemorrhage  from  which  renders  us  anxious, 
and  from  which  the  possible  presence  of  products  of  conception  is 
excluded,  should  we  see  an  irregular,  soft,  reddish-coloured  mass 
protruding  from  the  os  uteri  or  filling  its  calibre,  and  readily  bleed- 
ing, we  should  suspect  sarcoma  and  bring  the  microscope  to  our  aid 
to  confirm  the  diagnosis. 

Differentiation. — The  more  frequent  site  being  the  cavity  of  the 
body  of  the  uterus,  it  may  be  impossible,  save  by  the  micro- 
scope, to  differentiate  the  two  diseases.  Clinically  there  are  these 
distinctions — 

The  slower  course. 

The  connection  with  sterility -^twenty -five  out  of  sixty-three 

cases  (Gusserow). 
The  discharge  is  not  so  offensive  and  is  more  watery,  contain- 
ing greyish-white  shreds  of  sarcomatous  tissue. 
Pain  is  not  so  invariable  a  symptom.     Thomas  accounts  for 
the  absence  of  pain  in  some  cases,  to  which  special  atten- 
tion has  been  drawn  by  A.  R.  Simpson,  by  the  portion  of 
the  uterus  in  which  the  sarcoma  occurs.    If  the  sarcomatous 
groioth  he  parenchymatous  the  jjain  is  severe  ;  not  so,  if  it  he 
diffused  in  the  endometrium. 
Sarcoma  agrees  with  carcinoma  clinically  in — 


CANCER    OF  THE    UTERUS.  579 

The  tendency  to  recurrence ; 

The  haemorrhage  which  attends  it ; 

The  foul  discharge  after  ulceration  of  the  surface  ; 

The  pain  ; 

The  soft  and  friable  nature  of  the  growth  in  many  instances  ; 

Its   fatal   termination    (in    septicaemia,    haemorrhage,   peri- 
tonitis). 
For  diagnostic  purposes,  sarcoma  can  only  be  clearly  distinguished 
from  carcinoma,  fibioid  growth,  or  chronic  hyperplasia,  by  means  of 
the  microscope  and  the  detection  of  the  characteristic  spindle  or 
round  cell. 

Prognosis. — This,  in  every  form  of  malignant  disease,  is  most 
unfavourable.  The  average  duration  of  life  in  cases  of  cancer  of  the 
cervix  is  from  twelve  or  eighteen  months  to  three  years.  Such  a 
termination  as  spontaneous  recovery  has  been  recorded.  But  this  is 
so  rare  that  its  possibility  is  hardly  to  be  taken  into  consideration. 
On  the  other  hand,  if  the  disease  be  detected  very  early,  and  a 
partial  cure  be  attempted  by  removal  of  the  diseased  tissue  and  the 
free  use  of  the  cautery,  we  may  prolong  life,  if  we  do  not  succeed  in 
curing  the  disease.  Death  ultimately  takes  place  from  exhaustion, 
septicaemia,  or  peritonitis,  and  occasionally  from  hfemorrhage.  The 
only  step  to  be  relied  on  for  giving  the  woman  a  chance  of  life  for 
any  considerable  time  is  hysterectomy. 


CHAPTER    XXXII. 


CANCER   OF  THE   UTERUS    (continued). 
Treatment. 

We  may,  for  clinical  purposes,  divide  the  treatment  of  malignant 
disease  of  the  uterus  under  the  heads  of  imlliative  and  radical. 

Palliative  and  General  Treatment. 


The  actual  cautery. 
Chloride  of  zinc. 
Chromic  acid. 
Potassa  fusa. 
Nitric  acid. 
Carbolic  acid. 
Chlorate  of  potash. 
Chian    turpentine,    internally 
(Clay). 

Sedatives  internally  : 

Opium. 

Morphia,  subcutaneously. 

Nepenthe. 

Chloral  hydrate ;  chloralamid. 

Bromides. 

Cannabin. 

Hyoscyamus. 

Sedatives  locally : 

Belladonna  and  morphia  sup- 
positories. 
Cocaine. 
Anodyne  washes. 


Antiseptic  anpl  disinfectant  vaginal 


Condy's  disinfectant. 
Formalin  solution,  72  per  cent. 
Peroxide  of  hydrogen  solution, 

1  per  cent. 
Chloral  hydrate. 
Carbolic  acid. 
Boric  acid. 
Thymol. 

Chloride  of  zinc. 
Sulpho-carbolate  of  zinc. 
Tincture  of  iodine. 
Chinosol. 

Astringents : 

Per  chloride  of  iron. 
Sulphate  of  iron. 
Tannic  acid. 
Alum. 
Acetate  of  lead. 

Other  treatment : 

High-frequency  current. 
The  X  rays. 
Radium. 
Inoculation. 


CAXCEH   OF   TEE    UTERUS.  581 

Attention  to  the  Rectum. — The  .state  of  the  rectum  is  of  great 
importance.  The  occasional  use  of  enemata  or  saline  waters,  and 
aperient  confections  and  soft  food,  will  do  much  to  prevent  the 
accumulation  of  scyballa  and  consequent  pressure  on  the  diseased 
part. 

Caustics. — Of  various  caustics,  other  than  zinc  chloride,  fuming 
nitric  acid  is  one  of  the  best.  Its  mode  of  application  has  been 
previously  noticed,  as  has  also  that  of  potassa  fusa.  Chromic  acid 
(■^i — '^i.)  for  relieving  pain,  arresting  haemorrhage,  and  checking  the 
ulcerative  process,  I  have  always  found  of  great  service. 

Deodorants. — The  use  of  escharotics  must  be  combined  with  anti- 
septic and  disinfectant  applications,  in  order  to  keep  the  vagina  free  of 
the  tissue  debris,  and  prevent  the  horrible  odour  which  is  frequently 
present.  For  this  latter  symptom  Siredy  recommends  the  vaguia  to 
be  washed  out  with  a  solution  of  perchloride  of  mercury  (1  in  3000), 
after  which  a  plug  of  absorbent  cotton-wool  soaked  in  a  choral 
solution  (i  per  cent.),  and  dusted  with  iodoform,  is  applied  to  the 
cervix.  This  is  renewed  after  two  days,  and  reapplied  as  often  as 
it  is  deemed  necessary.  Condy's  fluid,  thymol,  chinosol  (1  in  600), 
formalin  (1  in  1000),  and  peroxide  of  hydrogen,  are  admirable  deodo- 
rants and  disinfectants. 

Sedatives. — Pain  may  be  relieved  both  by  local  suppositories  and 
pessaries,  and  the  internal  administration  of  sedatives.  Cocaine,  in 
my  hands,  both  locally  applied  and  used  subcutaneously,  has  failed 
to  give  rehef.  Morphia,  injected  subcutaneously,  is  the  best  means 
I  know  of  for  subduing  the  pain  of  uterine  cancer.  Its  use  should 
be  postponed  for  as  long  a  period  as  possible.  It  is  in  the  last 
stage  of  the  affection  that  it  is  so  necessaiy.  If  it  be  administered 
earlier  it  may  lose  its  effect,  and  fail  to  give  the  looked-for  relief 
when  it  is  most  needed.  It  is  a  good  plan  to  alternate  its 
administration  with  some  other  sedative,  or  a  different  preparation 
of  opium,  given  either  by  mouth  or  rectum.  Chloral  and  the 
bromides,  or  cannabis  indica,  lupuline,  hyoscyamus,  monobromate  of 
camphor,  conium,  heroin  with  codeine,  are  also  useful.  It  is  better 
to  give  the  full  dose  at  a  stated  hour  in  the  day,  generally 
approaching  night,  when  the  parts  have  been  dressed  and  the 
patient  has  had  any  local  treatment  appKed. 

Internal  Remedies. — The  more  carefully  we  consider  aU  the 
vaunted  '  cures '  of  cancer,  which  from  time  to  time  have  been 
practised,  the  more  we  must  realize  that,  up  to  the  present,  the  only 
treatment  which  can  be  accepted  as  having  any  claim  to  be  looked 


582  DISEASES   OF   WOMEN. 

on  in  the  light  of  a  *  cure  '  is  the  operative.  Whatever  the  future 
may  have  in  store  for  surgery  in  the  direction  of  the  X-ray,  radium, 
the  high-frequency  currents,  or  inoculation,  as  yet  there  is  nothing 
definite  to  rely  on.  . 

CMan  Turpentine. — Clay,  of  Birmingham,  placed  before  the  profession  some 
apparently  startling  cures  by  means  of  the  Chian  turpentine.  Having 
anxiously  tried  this  medicine  with  several  cases,  both  in  the  form  of  pills  and 
in  emulsion,  I  may  record  my  experience  of  its  effects.  In  several  instances 
it  certainly  appeared  to  arrest  the  disease,  to  lessen  the  pain,  and  to  check 
haemorrhage.  In  none  was  the  effect  permanent.  In  other  cases  it  decidedly 
restrained  the  hfemorrhage,  but  did  not  arrest  the  progress  of  the  disease.  In 
some  it  had  apparently  no  effect  whatever. 

The  combination  of  arsenic  and  quinine  in  the  cachexia  of  rqalignant 
disease  of  the  womb  is  useful. 

Haemorrhage  may  be  controlled  by  styptic  tampons.  These  must 
not  be  left  longer  in  the  vagina  than  twelve  hours.  The  use  of 
warm- water  injections  to  120°  should  be  tried,  with  the  liquid 
extract  of  hydrastis  and  tincture  of  matico  added.  Internally, 
astringents  may  be  given  in  combination  with  ergot,  also  Chian 
turpentine,  hydrastinine,  or  stypticine.  The  strength  of  the  patient 
must  be  maintained  by  a  nourishing  but  not  over-generous  diet. 
Some  stimulants  are  generally  necessary ;  the  kind  and  quantity  will 
depend  on  the  circumstances  of  the  case.  Change  of  air,  a  well- 
ventilated  sleeping  apartment,  cheerful  companionship — in  short, 
everything  that  can  contribute  to  make  the  life  of  the  patient  as 
fairly  comfortable  as  the  terrible  nature  of  the  malady  will  admit — 
should  be  advised. 

Treatment  by  the  X  Rays. — With  regard  to  the  treatment  of 
carcinoma  by  the  X  rays,  various  contrivances  have  been  devised 
to  concentrate  the  rays  on  growths,  both  in  the  rectum  and  vagina. 
Pennington  of  Chicago  devised  a  shield  of  metal,  which  clasps  the 
X-ray  tube  round,  and  has  a  cylindrical  prolongation  which  can  be 
used  as  a  speculum,  or  to  which  the  speculum  can  be  attached.* 
Cases  have  been  recorded  in  which  not  only  does  the  growth 
appear  to  have  been  arrested,  but  cicatrization  to  have  taken  place 
from  the  effects  of  the  rays. 

Cleaves,  Grubbe,  Scully,  and  Dawson  Turner  have  reported 
favourably  on  the  action  of  the  X  and  ultra-violet  rays  in  inoper- 
able cancer  of  the  cervix."}" 

*  Ann.  Gyn.  and  Fed.,  May,  1903, 

t  Amer.  Gyn.,  Nov.  1902 ;  Med.  Bee,  Nov.,  1902 ;  Amer.  Med.,  Feb.,  1903. 


CANCER    OF   THE    UTERUS.  583 

The  Reports  of  the  Cancer  Hospital  (London)  do  not  warrant 
any  definite  conclusions  being  drawn  from  the  X-rays  in  inoperable 
cases.  There,  again,  in  some  cases  arrest  of  the  growth  and  lessening 
of  the  pain  have  followed  the  treatment.  The  conclusion  is  that 
the  X-rays  may  be  tried  in  cases  in  which  operative  treatment  has 
effected  all  that  can  be  expected  of  it. 

Radium  Treatment. — The  results  of  the  radium  treatment  at  the 
Cancer  Hospital  are  also  most  disappointing,  and  the  reports  of 
Plumer  on  the  effects  are  practically  "  nil."  The  same  may  be  said 
of  the  inoculation  treatment. 

Animal  Extracts  in  Treatment  of  Carcinoma. — Bell,  of  Glasgow,  has  reported 
cases  of  carcinoma  in  which  amelioration  of  the  symptoms  has  followed  the 
administration  of  thyroid  extract.  Tliis  was,  however,  combined  with  active 
local  treatment,  the  application  of  iodized  phenol,  and  ichthyol  tampons,  and, 
in  some  cases,  with  curettage  and  caustics. 

In  cancer  of  the  body  of  the  uterus  there  is  nothing  to  add  to 
what  has  been  said  of  the  paUiative  treatment  of  malignant  disease 
of  the  cervix. 

Costive  Bowel. — The  clmical  fact  that  obstinate  costiveness  and  distension 
of  the  rectum  occurs  in  cases  of  scirrlms,  sliould  not  be  forgotten.  In  a  case 
of  cancer  of  the  body  of  the  uterus  in  a  lady  aged  fifty-five  years,  the  fatal 
termination  was  precipitated  by  the  accumulation  of  hardfajces  in  the  rectum. 
Every  means  failed  to  extract  these,  and  I  had  to  dilate  the  rectum  and 
remove  some  masses  with  the  hand.  One  was  of  stony  hardness;  with 
difficulty  could  I  saw  it  through  with  a  knife. 


Inoperable  Cancer. 

In  cases  of  inoperable  cancer,  the  actual  cautery  is  our  most 
powerful  means  of  arresting  the  spread  of  the  disease  and  checking 
hfemorrhaffe.  In  some  foreign  clinics,  as  in  that  of  Bumm,  the  old 
bullet-shaped  iron  cauteries  are  preferred  to  Paquelin's,  several  of 
these,  heated  by  gas,  being  kept  ready  to  hand.  The  patient  is 
placed  in  the  lithotomy  position  under  amesthesia.  The  vaginal 
walls  are  held  widely  apart  by  broad  retractors,  the  uterus  is 
exposed,  and  drawn  as  far  as  possible  towards  the  outlet.  With 
the  spoon  curette  as  much  necrotic  tissue  as  possible  is  removed, 
and  the  cavity  thus  left  is  dried  by  packing  with  gauze,  soaked  if 
necessary  in  some  styptic  solution,  such  as  alum,  perchloride  of 
iron,  or  peroxide  of  hydrogen.  The  Paquelin  knife  or  the  button 
end  is  then  applied.     Should  the  uterine  wall  be  thin,  caution  must 


584  DISEASES   OF    WOMEN. 

be  exercised  in  order  to  avoid  injury  to  either  the  bladder  or  rectum. 
When  the  cauterization  is  finished,  the  cavity  is  packed  with  gauze 
soaked  in  strong  perchloride  of  iron  solution,  or,  what  I  prefer, 
that  of  chloride  of  zinc  (one  drachm  to  the  ounce). 

Lomer  has  recently  written*  on  the  use  of  the  cautery  in 
cancer  of  the  uterus,  and  the  beneficial  effects  which  follow  its 
application,  noting  the  variable  results  in  point  of  time  before 
recurrence  of  the  disease  in  213  cases.  The  effect  of  the  cautery 
in  causing  the  death  of  the  cancer  cells,  and  the  influence  of  heat 
on  their  vitality,  he  thinks  account  for  this.  He  also  believes 
that  the  extreme  exhaustion  which  follows  from  profuse  haemor- 
rhage from  cancer,  and  the  drain  on  the  system,  tend  to  arrest  the 
progress  of  the  growth.  He  tried  hsemolitic  serum,  suggesting  that 
an  epithelial  serum  may  also  be  found  which  will  have  a  preventive 
influence  on  carcinomatous  growth,  even  a  specific  form  of  serum 
for  each  variety  of  the  disease.  He  inclines  to  the  administration 
of  chloride  of  potash  and  arsenic,  the  former  also  being  used  for 
vaginal  irrigations.  He  advises  the  repeated  application  of  the 
cautery  in  inoperable  cases. 


Operative  Treatment  of  Cancer  of  the  Cervix. 

Once  carcinoma  of  the  cervix  is  discovered,  the  uterus  should  be 
removed.  In  view  of  our  present'  knowledge,  to  adopt  any  other 
course  is  to  subject  the  woman  to  the  gravest  risk  of  the  spread  of 
the  disease,  and  to  deprive  her  of  the  chance  of  cure,  or  at  least 
prolongation  of  life. 

If  the  patient  decline  to  submit  to  the  radical  operation,  at 
least  the  minor  step  should  at  once  be  taken  of  high  amputation 
of  the  diseased  cervix.  And  this  does  not  interfere  with  resort 
to  the  more  radical  measures  subsequently,  if  there  be  recurrence 
of  the  disease. 

Freund  insists  that  the  diagnosis  of  cancer  is  an  immediate  indication  for 
the  total  extirpation  of  the  uterus,  and  that  the  operation  thus  early  performed 
at  the  commencement  of  the  disease  offers  the  best  prospect  of  a  permanent 
cure.  The  abdominal  operation  he  thinks  better  than  the  vaginal  one,  which 
latter  should  be  reserved  rather  as  a  palliative  step  for  cases  in  which  the 
radical  operation  is  unsuitable. 

*  Zeitch.  f.  Geb.  und  Gyn.,  1904. 


CANCER   OF  THE    VTERUS.  585 


Influence  of  the  Lymphatic  Distribution  on  the  Operative 
Treatment  of  Cancer. 

Various  authorities  differ  considerably  as  to  the  percentage  of  glandular 
involvement  in  uterine  cancer,  but,  as  Gellhorn  points  out,  they  are  derived 
from  post-mortem  records  of  women  who  '  had  died  from  a  far-advanced  stage 
of  cancer,'  and  many  had  not  been  verified  by  the  microscope,  which  method 
of  examination  is  not  itself  without  possibilities  of  error.  In  68  cases,  cohected 
by  Gellhorn,  of  abdominal  radical  operation,  the  glands  were  affected  in  from 
34  to  35  per  cent. ;  and  in  86  other  cases  the  percentage  of  the  entire  number 
Avas  about  the  same— in  a  total  of  128  cases  the  amount  being  33-6  per  cent. 

Tt  would  appear,  from  the  researches  of  various  authorities,  that 
in  the  early  stages  of  the  primary  growth  in  the  cervix  the  glands 
are  more  frequently  involved  ;  and  the  view  of  Cullen,  with  regard 
to  the  frequency  of  glandular  involvement  in  carcinoma  of  the  portio, 
appears  to  be  generally  true,  namely,  '  that  the  growth  must 
extend  far  out  into  the  broad  ligament  before  infection  of  the  lym- 
phatic glands  can  take  place.  Jordan  shows  that  among  twenty- 
seven  cases  of  cancer  of  the  colon  there  were  seventeen  with 
intact  glands,  though  ten  out  of  the  seventeen  presented  the  disease 
in  an  advanced  stage.  His  conclusion  generally  is,  that  glandular 
involvement  from  cancer  of  the  uterus  is  comparatively  rare,  and 
when  it  does  occur  it  is  in  the  latter  stages  of  the  disease.  Kelly 
comes  to  the  conclusion  that  extension  of  cervical  cancer  per  con- 
tinuitatum  is  the  rule,  extension  by  glandular  metastases  per  saltum 
unusual,  in  the  early  stages  of  the  disease. 

With  regard  to  glandular  involvement  in  cancer  of  the  body, 
authorities  are  generally  in  accord  with  the  views  of  Cullen,  that 
the  inguinal  glands  are  rarely  invaded  by  the  carcinoma.  On  the 
whole,  the  conclusions  of  Gellhorn,  from  the  pathological  reports  of 
a  variety  of  operators,  both  as  to  the  involvement  of  the  glands  by 
carcinomatous  invasion,  and  also  secondary  metastases,  tend  to 
prove  that  we  have  not  sufficient  data  to  support,  at  least  up  to 
the  present,  the  proposal  of  some  operators  to  perform  the  more 
extensive  operation  with  removal  of  all  the  glands  and  the  para- 
metrium, save  in  exceptional  cases  of  carcinoma.  He  asks,  How  is 
the  operator  to  know  whether  and  where  he  will  discover  suspicious 
glands  1  Is  he  able,  before  or  during  the  operation,  to  detect  the 
presence  of  enlarged  glands?  Authorities  are  somewhat  divided  as 
to  the  possibility,  even  under  anaesthesia,  and  by  any  method  of 
examination,  of  palpating  the  pelvic  and  lumbar  glands.     Even  the 


586  DISEASES  OF   WOMEN. 

exponents  of  the  more  radical  methods,  such  as  Wertheim  and 
Funke,  and  such  careful  investigators  as  Cullen,  Winter,  Irish, 
and  Kronig,  declare  the  impossibility  of  glands,  even  up  to  the  size 
of  a  pigeon's  egg,  being  determined  by  touch  before  operation.  On 
the  other  hand,  the  lymphatics  of  the  broad  ligaments  have  been 
invaded  and  found  indurated,  and  the  lymph  channels  and  lymph 
vessels  impregnated  with  carcinoma,  the  carcinomatous  elements 
not  being  filtered  by  or  deposited  in  the  glands.  According  to 
Cullen,  the  carcinomatous  growth  spreads  far  out  into  the  broad 
ligament  before  involvement  of  the  lymphatic  gland  occurs,  a  view 
corroborated  by  several  authorities. 

Conclusions. — We  thus  come  to  the  three  views  as  to  the  extent 
of  the  radical  procedure  which  should  be  carried  out.  First,  there 
are  those  in  America  and  the  Continent  who  advocate  the  extreme 
radical  step  in  which,  as  a  routine  procedure,  all  glands  are  removed 
as  a  preliminary  measure  in  the  technique  of  hysterectomy,  and  such 
operators  ablate  the  whole  lymphatic  and  glandular  system  of  the 
pelvic  cavity  with  the  parametric  tissue,  even  including  the  rectum 
when  necessary — Amann,  by  the  transperitoneal  method,  removing 
the  greater  part  of  the  vagina  with  all  the  pelvic  glands  and  their 
lymph  vessels,  the  infiltrated  and  the  non-infiltrated,  and  the  con- 
nective tissue  structures  of  the  lateral  and  anterior  regions  of  the 
pelvis. 

Next  we  find  a  class  of  operators  who  follow  Wertheim's  method, 
who  does  not  proceed  beyond  the  bifurcation  of  the  aorta  in  any 
case  while  extirpating  the  gland,  and  only  removes  the  latter  in 
a  certain  percentage  of  cases.  Such  operators  as  Doederlin  and 
Zweifel  remove  only  such  glands  as  are  palpable  or  suspicious ;  as 
also  Funke,  Menge,  and  Kronig,  these  latter  placing  as  much 
importance  on  the  ablation  of  the  parametria  as  of  the  glands. 
Lastly,  v/e  find  a  number  of  operators  of  such  standing  as  Jacobs, 
Olshausen,  v.  Ott,  and  Hofmeier  denying  the  possibility  of  the  removal 
of  the  glands  in  their  entirety  or  the  lymph  channels,  search  we 
ever  so  carefully  during  operation ;  and  Gellhorn,  in  his  exhaustive 
review,  in  noticing  the  attachment  of  the  carcinomatous  glands  to 
the  large  bloodvessels,  says  that  it  occurs  to  him  that  under  such 
conditions  any  operation  would  be  utterly  useless,  and  he  asks  the 
two  crucial  questions — Is  the  systematic  removal  of  glands  really 
necessary?  Has  it  improved  the  final  results  of  the  less  radical 
method?  In  answer  to  these  queries,  he  shows  that,  from  the 
recurrences  after  the  extreme  radical  methods  in  the  best  hands, 


GAXCKK    OF   THE    UTEJiUS.  n87 

such  as  those  of  "Winter,  Schauta,  Wertheim,  Terrier,  and  Kelly, 
it  is  questionable  if  the  removal  of  the  glands  is  necessary,  or  has 
added  to  the  value  of  the  radical  operation.  Reviewing  the  entire 
subject,  it  would  appear,  so  far  as  our  present  knowledge  of  these 
extreme  radical  methods  and  removal  of  the  glands  are  concerned, 
that  the  results  are  hardly  more  hopeful  than  those  obtained  by  a 
free  pan-hysterectomy,  with  removal  of  such  glands  as  may  be  felt, 
the  involved  parametria,  and  the  ablation  of  as  much  of  the  vagina 
as  may  be  called  for. 

Of  140  cases  of  abdominal  radical  operation  for  cancer,  reported 
on  by  Oehlecker,  the  glands  were  affected  in  35  per  cent. ;  and  in 
30  per  cent,  they  were  enlarged  by  hyperplasia  and  infiltration, 
without  cancerous  deposit.  In  seven  of  Olshausen's  patients  who 
died  after  the  vaginal  operation,  the  glands  were  enlarged  in  all 
cases,  and  iu  some  30  per  cent,  metastases  w^as  present.* 

Minor  Operations. 

Amputation  of  the  diseased  cervix  is  performed  either  with  the 
galvanic  or  wire  ecraseur,  Paquelin's  knife,  a  scissors,  or  scalpel. 
The  latter  is  certainly  preferable.  In  all  these  operations  the 
dangers  to  avoid  are  :  (a)  Haemorrhage,  (h)  Injury  to  the  bladder 
or  rectum.  The  most  important  points  to  attend  to  are  :  Complete 
removal  of  the  diseased  tissue  by  cutting  through  to  the  healthy 
structure  outside  it,  and  the  destruction  of  any  infiltrated  tissue 
after  removal  of  the  disease  by  the  free  use  of  caustic  or  cautery. 

Schrceder  performed  two  minor  operations,  one  diU  infra-vaginal,  the  other 
a  supra-vaginal,  amputation,  of  the  entire  cervix.  In  both  these  operations 
the  knife  is  used,  and  the  wounds  are  closed  by  sutures.  In  the  infra -vaginal 
operation,  having  first  created  anterior  and  posterior  lips,  a  wedge-shaped 
portion  is  removed  from  both.  In  the  supra- vaginal,  the  incisions  are  made 
through  the  vaginal  mucous  membrane  in  either  fornix.  The  bladder  and 
Douglas'  pouch  are  carefully  avoided.  The  cervix  is  cleared  of  its  cellular 
tissue,  and  the  amputation  is  completed  by  the  final  stitching  of  the  anterior 
and  posterior  vaginal  walls,  which  are  united  to  those  of  the  uterus.  Ligature 
of  the  uterine  arteries  considerably  facilitates  the  steps  of  the  operation. 

The  Cralvanic  Ecraseur. — The  patient  is  anaesthetized,  and,  when  the  uterus 
is  thoroughly  exposed,  the  cautery  loop  is  sHpped  on  cold  and  pushed  as  far 
as  possible  on  to  the  healthy  tissue ;  the  current  is  applied,  and  the  wire  is 
tightened  slowly ;  slight  traction  is  made  while  it  cuts  through,  so  as  to  secure  a 
funnel-shaped  stump  (Byrne  of  Brooklyn).  The  mucous  membrane  is  divided 
circularly  with  an  ordinary  knife,  and  detached  for  a  short  distance.     The 

*  Zeitsch.  f.  Geb.  u.  Gyn.,  bd.  48,  heft  2. 


588  'DISEASES^ OF   WOMEN. 

section  is  then,  completed  with  the  curved  Paquelin  knife,  by  the  use  of  which 
there  is  very  little  bleeding. 

In  using  the  chain  or  wire  ecraseur,  the  uterus  has  to  be  drawn  well  down 
and  fixed  by  a  vulsellum.  The  uterine  arteries  may  be  first  secured,  the 
uterus  bisected,  and  either  half  removed.  The  screw  must  be  worked  slowly. 
The  stump  should  be  treated  with  the  actual,  Paquelin's,  or  the  electric  (porce- 
lain) cautery  (p.  144). 

Tliermo-Cautery. — The  therm o-cautery  is  applied  to  the  ulcerated  cervix 
after  free  scraping  of  the  ulcerations.  If  the  interior  of  the  uterus  be  affected 
the  cervix  is  fully  dilated,  a  saturated  solution  of  chloride  of  zinc  is  applied, 
and,  after  cauterization,  the  cavity  is  packed  with  iodoform  gauze  or  cotton- 
wool (Vuillet). 

The  curette  must  be  applied  freely,  according  to  the  extent  of  the  disease. 
If  the  cancerous  infiltration  should  have  encroached  on  the  wall  of  the  bladder 
in  front,  or  the  peritoneum  posteriorly,  care  must  be  taken  to  avoid  opening 
into  the  peritoneum,  bladder,  or  rectum.  After  the  use  of  the  curette, 
PaqueHn's  cautery,  the  tampon  of  chloride  of  zinc,  or  the  alcoholic  solution 
of  bromine  (Routh  and  Schrceder),  1  part  to  5,  chromic  acid,  or  peroxide  of 
hydrogen,  may  be  applied.  The  free  use  of  the  cautery  is  to  be  preferred. 
If  bromine  be  selected,  some  cotton-wool  saturated  with  the  solution  is  pressed 
against  the  surface  of  the  wound,  and  the  vagina  is  subsequently  well  plugged 
with  a  tampon  either  soaked  in  a  solution  of,  or  covered  with,  carbonate  of 
soda.  The  bromine  tampon  may  be  left  in  for  twenty-four  hours.  The 
application  may  be  renewed  in  about  ten  days  if  necessary. 

'  I  have  seen,'  says  Spencer  Wells,  '  several  cases  treated  by  the  late  Wynn 
Williams  with  bromine,  but  not  one  ended  satisfactorily,  although  temporary 
good  was  done.' 

Chloride  of  Zinc. — The  steps  of  the  method  advocated  by  Marion  Sims  are 
as  follows:  (1)  The  bed  of  the  diseased  mass  in  the  supra-vaginal  cervix  is 
removed  with  the  knife,  scissors,  or  spoon.  (2)  The  cavity  is  dried,  cleaned, 
and  prepared  for  the  styptic  application.  (3)  The  dried  cavity  is  plugged  with 
cotton-wool,  which  is  squeezed,  nearly  dry,  out  of  sub-sulphate  of  iron  solution, 
or  weak  solution  of  carbolic  acid  saturated  with  powdered  alum.  The  upper 
part  of  the  vagina  is  packed  with  the  same,  and  the  lower  portion  with  simple 
carbolic  solution.  In  five  days  the  plug  is  removed.  Some  pledgets  of  cotton- 
wool are  squeezed  dry  out  of  a  solution  of  five  drachms  of  chloride  of  zinc  to 
the  ounce,  and  packed  into  the  uterine  cavity.  The  upper  part  of  the  vagina 
is  plugged  with  cotton-wool  soaked  in  carbonate  of  soda  solution.  All  is 
removed  after  four  days. 

I  have  on  some  occasions  used  chloride  of  zinc  with  excellent  results, 
leaving  only  a  shell  of  the  uterus. 

Jessett  showed,  at  the  Gynsecological  Society,  the  cast  of  an  entire  uterus 
removed  by  packing  with  chloride  of  zinc  paste.  He  places  a  gutta-percha 
covering  over  the  whole,  and  neutrahzes  the  caustic  with  carbonate  of  soda. 

Browne  and  Munde  have  recorded  cases  in  which,  after  the  uterus  was 
curetted  and  tamponed  by  the  former  surgeon  with  zinc  chloride,  and  by 
the  latter  with  perchloride  of  iron,  the  entire  organ  came  away  on  the  tenth 
day  in  both  instances. 


CANCER    OF   THE    UTERUS.  589 

Meinert  *  also  strongly  advocated  the  treatment  by  chloride  of  zinc.  He 
uses  the  mixture  of  equal  parts  of  chloride  of  zinc  and  starch  to  form  a  paste. 

Choice  of  Operation. — On  the  much-debated  question,  as  to  which 
form  of  operation  is  to  be  advised,  and  the  nature  of  the  technique 
to  be  followed  in  carcinoma  of  the  uterus,  views  of  prominent 
gynfticologists  materially  differ.  Our  course, ^however,  will  be  in 
great  measure  determineil  by  the  situation  of  the  disease,  its  extent, 
and  the  degi-ee  to  which  the  lymphatics  of  the  pelvis  and  the  para- 
metrium are  involved. 

Hysterectomy  by  the  vaginal  route  has  come  to  be  regarded  as 
the  treatment  for  cancer  of  the  cervix  and  portio,  once  the  presence 
of  malignant  disease  has  been  established.  In  the  same  manner, 
in  cancer  or  any  form  of  malignant  disease  of  the  body,  when  it 
has  not  extended  beyond  the  uterus,  and  the  parametrium  is  free, 
vaginal  hysterectomy  is  indicated.  On  comparing  the  results  of 
partial  operative'  procedures  with  the  more  radical  measure,  it  is 
apparent  that  there  is  little  to  gain  by  advising  the  former  course 
when  we  offer  so  much  greater  security  for  the  sufferer  by  the  com- 
plete removal  of  the  diseased  organ,  ■]■  If  the  disease  be  detected 
very  early,  and,  while  it  is  yet  limited  to  the  cervix,  a  Schroeder's 
high  amputation  be  performed,  the  results  are  by  some  still  con- 
sidered sufficiently  good  to  warrant  the  choice  of  this  measure 
instead  of  that  of  hysterectomy,  and  as  compared  with  the  radical 
operation,  the  gain  in  life  appears  to  be  not  much  less.  On  the 
other  hand,  it  cannot  be  denied  that  early  and  complete  ablation 
of  the  diseased  organ,  before  the  lymphatics  of  the  pelvic  glands 
have  become  seriously  involved,  offers  the  patient  the  greatest 
certainty  of  the  removal  of  the  entire  disease.  Recurrence  varies, 
in  the  majority  of  such  favourable  cases,  from  a  period  of  two  to 
six  years.  Some  50  per  cent,  of  all  cases  recur  within  a  period  of 
time  varying  from  eighteen  months  to  three  years.  Five  years 
must  be  taken  as  the  lowest  limit  to  speak  of  '  non-recurrence '  of 
the  disease. 

After  total  hysterectomy,  a  relatively  small  number  survive  this 
period,  and  live  for  a  longer  time  without  recurrence,  while  a  com- 
parative few  escape  altogether  from  the  reinvasion  of  the  cancer. 
As  Japp  Sinclair  says,  '  though  called  major,  the  radical  operation  is, 
perhaps,  less  dangerous  than  many  of  the  so-called  minor  operations,' 
Gradually,  therefore,  the  minor  operative  procedures  have  given 

*  Muench.  Med.  WcJais.,  1902,  Xo.  39. 

t  The  statistics  of  Schrceder.  Verneuil,  Winter,  and  Leopold  proved  this. 


590  DISEASES   OF   WOIIEN. 

place  to  the  two  methods  of  hysterectomy :  firstly,  that  by  the 
vao'inal  route  ;  and  secondly,  that  by  the  abdominal.  The  question 
whether  an  operation  is  warrantable  or  not,  depends  altogether 
upon  the  degree  of  extension  of  the  disease.  Given  a  movable 
uterus  and  one  capable  of  being  drawn  down  to  the  vulva,  and 
where  the  broad  ligaments  and  the  pelvic  glands  are  not  implicated, 
there  need  be  no  hesitation,  and  here  the  operation  of  selection  is 
that  by  the  vagina.  Even  in  cases  in  which  the  portio  vaginalis 
is  involved,  and  there  is  vaginal  infiltration,  the  feasibility  of 
removing  the  entire  vagina  proves  that  in  such  cases  the  involve- 
ment of  the  vaginal  fornix  need  not  deter  us  from  operation.  On 
the  other  hand,  if  the  disease  should  have  extended  beyond  the 
uterus,  and  the  broad  ligaments  or  the  glands  be  implicated,  or  if 
the  disease  be  complicated  with  a  myoma,  the  facility  for  reaching 
these  extra-uterine  structures  offered  by  the  abdominal  route  makes 
it  either  alone  or  combined  with  the  vaginal,  the  most  favourable 
operation  for  such  cases. 

Vaginal  Hysterectomy  for  Cancer.'- — We  have  already,  in  the  case 
of  myomata,  described  the  various  methods  of  performing  vaginal 
hysterectomy  in  the  case  of  tumours  of  the  uterus.  The  operation 
necessarily  varies  somewhat  in  the  instance  of  cancer  of  the  neck  or 
body  of  the  uterus.  The  probability  of  recurrence,  the  extent  of 
the  cancerous  infiltration,  and  the  involvement  of  glands,  necessitate 
the  wide  removal  of  the  disease.  Therefore,  in  all  cases,  the  uterus 
is  first  thoroughly  curetted,!  and  a  section  of  the  neck  having  been 
made,  the  lips  are  gtitched  together,  and  for  purposes  of  traction 
are  held  by  strong  suture  threads.  Other  surgeons,  howevei^;  prefer 
the  use  of  the  tenacula,  or  after  curettage  use  Orthmann's  instru- 
ment (Fig.  187)  to  grasp  the  uterus.  Others,  again,  amputate 
the  diseased  cervix  with  the  Paquelin's  knife  before  proceeding  to 
remove  the  uterus.  Also,  in  operation  for  cancer,  the  friability  of 
the  invaded  tissues  has  to  be  remembered,  and  it  is  specially  neces- 
sary, by  most  careful  examination  and  exploration  beforehand,  to 
estimate  the  degree  of  involvement  of  the  rectum,  bladder,  and 
parametrium.  Kelly  adopts  Pawlik's  recommendation  to  pass  a 
ureteral  bougie  in  those  cases  in  which  we  fear  inclusion  of  the 

*  The  different  methods  of  performing  vagmal  hysterectomy  have  been  already 
described  in  treating  of  myoma  and  pelvic  suppurations. 

t  Some  authorities  demur  to  the  preliminary  curettage  in  certain  cases  as  too 
exhausting  to  the  patient,  and  adding  to  the  risk  through  the  undue  prolonging 
of  the  operation  (Cullen— Wertheim). 


CANCER    OF   THE    UTEBim. 


591 


ureters,  as  a  guide  to  their  avoidance  during  the  operation.  Under 
any  circumstances  the  detachment  of  the  bladder  and  the  avoidance 
of  the  uret(n's  is  the  most  important  and  delicate  part  in  the 
operation  for  cancer.  Gentleness  in  working  with  the  finger 
towards  the  uterus,  and  the  use  of  a  small  sponge  in  separating  the 
bladder,  will  go  far  to  prevent  the  first  accident ;  keeping  the 
scissors  close  to  the  uterine  neck,  and  cutting  towards  the  uterine 
tissue,  the  second. 

Where  necessai'y,  an  incision  of  the   vaginal  mucous  membrane 
with  the  scissors,  a  few  centimetres  outside  the  limits  of  the  i,Towth, 


Fig.  416. — Cervix  held  bt  Short  8ilk  Sutures  which  have  beex  passed  for 
Tractiox  after  Curettage  of  the  Extire  Uterine  Cavity.  (Howard 
Kelly.) 

is  made  at  either  side,  and  these  marginal  incisions  are  connected 
with  that  over  the  anterior  surface  of  the  uterine  neck.  The 
mucous  membrane  is  then  detached  by  the  left  index-finger  from 
side  to  side,  and  this  is  followed  by  careful  separation  of  the  bladder 
in  the  manner  already  described.  Should  the  bladder  be  un- 
avoidably injured,  it  is  immediately  sutured.  Having  completed 
the  opening  of  the  anterior  cul-de-sac  and  the  attachment  of  the 
bladder,  the  posterior  cul-de-sac  is  incised  with  scissors,  and  the 
uterus  and  broad  ligaments  are  explored  through  the  opening.  Any 
detachment  from  the  cellular  connections  are  here  effected  by  the 


592 


DISEASES   OF   WOMEN. 


scissors.  The  uterus  is  now  removed  by  ligation  of  the  vessels  from 
below  upwards,  first  at  one  side,  then  at  the  other,  with  section  of 
the  broad  ligaments.  Finally,  the  adnexa  are  drawn  down  and  the 
ligatures  ai-e  applied  outside  these,  as  in  the  case  of  pan-hysterectomy 
for  myoma.  The  ligation  and  section  are  made  as  far  as  possible 
from  the  uterus,  and  any  invaded  glands  which  are  found  are  at  the 
time  removed.  If  the  cancer  be  in  the  body  of  the  uterus,  or  have 
invaded  it,  and  there  is  consequent  enlargement,  after  the  disinfec- 
tion of  the  canal  it  may  be  necessary  to  reduce  the  bulk  of  the 
uterus  by  hemisection,  and  remove  either  half  separately,  or  it  may 


YiQ.  417. — Antekioe  Incision  achoss  thk  Gkkvix  tu  free  it  fkum  the 
Vaginal  Vavlt  under  Irrigation.    (Howard  Kelly.) 

be  reduced  by  a  V-incision  of  the  anterior  wall.  It  is  always 
necessary  to  prevent  escape  of  the  infiltrating  neoplasm  into  the 
pelvic  cavity  and  the  peritoneum,  so  as  to  avoid  the  dangers  of 
infection. 

In  cases  of  difficulty,  having  first  catheterized  the  ureters,  Kelly  bisects  the 
utenis  from  above  downwards,  and  then,  allowing  retraction  of  one  half  with- 
in the  vagina,  the  cervix  is  seized,  and  the  body  of  the  uterus  is  severed  from 
it  by  dividing  from  within  outwards.  Next,  the  uterine  vessels  are  clamped, 
the  detached  body  is  drawn  further  out,  and  the  round  ligament  is  clamped, 
as  well  as  the  uterine  cornu.  One  quadrant  of  the  uterus  is  thus  removed, 
and  the  opposite  side  is  dealt  with  in  a  "similar  manner.    Ligatures  having 


CANCER   OF  THE    UTERUS. 


593 


been  applied,  the  clamps  arc  taken  olf  and  the  adncxa  then  removed.  The 
ablation  of  the  cervix  follows.  That  half  which  is  least  implicated  is  tirst 
removed.  Space  is  thus  afforded  for  the  exsection  of  the  remaining  lialf  of 
the  cervix,  and  this  is  done  either  by  ligature  or  the  electro-thermic  cautery. 
Kelly  does  not  hesitate  in  certain  cases,  if  the  ureter  cannot  bo  left  intact,  or 


Ftg.  41  S. — Fun;  Pieces  of  a  Caijcerocs  Uterus  extirpated  by 

QUADKISECTIOX.      (HoWARD   KeLLY.) 

On  the  right  side  a  large  section  of  the  ureter  has  been  nmoved  with  the 

cervix. 

dissected  out,  to  cut  it  across,  and  after  the  enucleation  is  over  to  transplant 
it  into  the  denuded  bladder  and  fix  it  there.  Finally,  he  draws  down  the 
anterior  and  posterior  peritoneal  surfaces,  attaching  them  to  the  vagina,  and 
sutures  them  m  the  middle  line,  so  as  to  leave  but  two  small  openings  into 
the  pelvis,  which  are  stuffed  with  gauze.* 

In  removing  a  very  enlarged  uterus,  or  in  cases  of  small  vaginal 
outlets,  it  may  be  necessary  to  incise  laterally  the  posterior  com- 
missure as  far  back  as  either  side  of  the  rectum,  which  will  give  the 
necessary  room.  I  use  the  vaginal  tap  or  douche  retractor  already 
described  for  irrigation  (Fig.  105).  This  latter  washes  away  any 
clots,  and  quickly  clears  the  bleeding  surfaces. 


Duties  of  Assistants— Retractors,  Ligatures,  Irrigation. 

There  is  no  more  important  duty  of  assistants  in  the  operation  of  vaginal 
hysterectomy  than  that  of  the  proper  use  of  the  right  retractors  during  the 
steps  of  the  operation.  Awkward  assistants  prevent  the  proper  exposure  of 
the  parts  and  the  due  protection  of  both  bladder  and  rectum.  The  lateral 
retractors  should  be  held  well  into  the  vagina  at  either  side,  holding  back  its 
walls  so  as  to  leave  sufficient  room  for  the  exposure  of  the  parts  to  be  liga- 
tured, the  admission  of  the  finger  for  exploration,  and  the  carrying  of  the 
needles  over  the  broad  ligaments.  These  retractors  have  been  figured  in 
describing  the  operation  for  myoma.f  Again,  the  triangular  retractor  of 
^lartin  should  be  slipped  well  in  underneath  the  bladder  and  held  securely  up 


*  See  chapter  on  the  Ureters. 


t  See  pp.  518,  ")19,  and  521. 
2  Q 


594 


DISEASES   OF    WOMEN. 


against  the'  pubes,  unless  the  operator  desires  its  removal  for  purposes  of 
exploration.  The  large  posterior  retractor  is  likewise  held  steadily,  depressing 
well  the  rectum  and  perineum. 

Another  point  of  importance  to  impress  on  assistants  is  the  tension  they 
use  in  holding  ligatures.  If  these  be  too  much  drawn  on,  they  are  apt  to 
slip  and  give  rise  to  most  troublesome  haemorrhage.  Therefore,  as  soon  as 
the  part  to  be  ligated  is  severed,  all  traction  on  the  ligature  should  cease.  If 
there  be  difficulty  in  securing  a  bleeding  vessel,  and  any  uncertainty  remains 


Pig.  419. — Sepaeation  of  the  Bladder  from  the  Cervix,  and  the 
Application  of  Retractors.     (Howard  Kelly.) 

as  to  its  safety,  it  is  far  better  to  treat  it  by  forcipressure,  and  leave  the 
forceps  on,  than  to  take  any  chance  of  subsequent  haemorrhage. 

Irrigation. — The  assistant  who  irrigates  should,  at  the  commencement  of 
the  operation,  regulate  the  stream,  which  should  not  be  too  strong,  but 
suflicient  to  play  lightly  on  the  part,  so  as  to  wash  away  the  blood  and  keep 
the  surface  clean.  The  fiushiug  retractor  or  pipette  should  be  held  steadily, 
and  turned  in  the  direction  required  without  the  necessity  of  a  word  from  the 
operator.  There  is  an  art  also  in  the  use  of  dabs  or  sponges.  The  nurse  or 
assistant  should  have  a  few  light  and  long  clamp  forceps,  and  these  should 
be  alternately  used  with  the  different-sized  pieces  of  gauze,  or  small  ready- 
made  dabs,  according  as  they  are  required.  The  handing  of  the  proper-sized 
dab  or  compress,  the  light  wiping  of  the  part  so .  as  not  to  disturb  ligatures, 
and  the  exercise  of  the  proper  pressure  on  a  bleeding  surface  or  vessel,  are- all 
points  to  be  carefully  attended  to,  and  are  only  to  be  acquired  by  practice. 

Schauta  adopts  the  plan  of  A.  Martin,  of  suturing  the  peritoneum  to  the 
anterior  vaginal  wall,  and  does  the  same  posteriorly.     He  also  divides  the 


CANCER   OF   THE    UTERUS. 


595 


ntcrus  into  two  parts,  in  cases  in  which  there  is  didiciilty  in  removal  from 

infiltration  or  adhesions.     His  needle-holder,*  which  has  been  already  figured 

is    most    convenient    for  the 

vaginal   operatioTi,  the  curve 

in  tlie  handle  allowing  it  to  be 

passed  deeply  at  either  side. 

He  uses  Ehrenfest's   ligature 

tightener  when  he  has  to  secure 

the  ligature  at  a  ;considerable 

depth  or  high  up  in  the  pelvis. 

He  does  not  cut  his  ligatures 

short,   but    leaves    them    for 

snliscqucnt  removal. 

Doyen's  Vaginal  Hysterec- 
tomy in  Cancer. — As  regards 
vaginal  hysterectomy,  Doj'en 
has  divided  his  procedure  into 
the  following  stages : — 

'  First  stage :  incision  of  the 
posterior  fornix,  opening  of 
Douglas'  pouch,  and  explora- 
tion of  the  pelvic  cavity. 
Second  stage :  incision  of  the 
anterior  fornix  and  separation 
of  the  bladder.  Third  stage  : 
crushing  of  the  lower  and 
middle  parts  of  the  broad 
ligaments.  For  this  jjurpose 
the  angiotribe  is  applied  on 
each  side  for  from  fifteen  to 
twenty  seconds.  The  uterus 
can  then  be  easily  di-awn  down. 
Fourth  stage :  anterior  hemi- 
section  of  the  uterus,  either 
by  median  or  by  V-shaped  incision,  and  drawing  down  of  the  uterine  fundus. 
For  a  small  uterus  the  median  incision  suffices  to  allow  the  fundus  and  the 
adnexa  to  be  brought  do^vn;  for  a  larger  tumour  the  V-shaped  incision  is 
employed.  Fifth  stage :  application  of  a  pressure  forceps  on  each  broad 
ligament  and  separation  of  the  uterus.  Sixth  stage  :  crushing  of  the  upper 
border  of  the  broad  ligament  and  application  of  ligatures.  After  the  applica- 
tion of  the  angiotribe  for  from  fifteen  to  twenty  seconds  above  the  pressiu-e 
forceps,  a  silk  thread  is  tied  in  the  groove  formed  by  it.  As  the  threads 
are  gradually  tightened,  the  assistant  cautiously  removes  the  angiotribe.  A 
single  thread  thus  embraces  each  broad  ligament.  Seventh  stage :  peritoneal 
toilet,  co-aptation  of  the  peritoneal  flaps,  and  tamponing  of  the  vagina.' 

Results  of  the  Radical  Operation. — Franz  asserts  tlmt  all  past 

*  See  p.  520. 


Fig.  420. — Detachment  by  Scissors  of  the 
Vaginal  Collaeette.    (Doykn.) 


596  DISEASES   OF   WOMEN. 


statistics  prove  that  10  per  cent,  of  women  suffering  from  carci- 
noma of  the  neck  of  the  uterus  remain  free  from  recurrence 
for  five  years,  after  the  operation,  and  that  permanent  cures 
of  cancer  of  the  body  amount  to  60  per  cent.  Thus,  taking  a 
hundred  women  affected  with  carcinoma  of  the  cervix,  assuming 
that  sixty  are  inoperable  and  forty  treated  by  vaginal  total  extir- 
pation, thirty  will  suffer  from  recurrence  within  five  years  after 
operation,  and  ten  will  be  permanently  cured.  This  supposititious 
example  accords  closely  with  actual  facts.  Schuchardt,  by  his 
operation  (see  p.  600),  secured  five  years'  freedom  from  recurrence 
in  40  per  cent,  of  his  cases,  though  he  did  not  remove  the  pelvic 
lymphatic  glands.  While  the  mortality  from  the  vaginal  operation 
may  be  said  'to  be  from  3  to  6  per  cent.,  we  may  estimate  that  of 
the  abdominal  at  the  lowest  as  some  10  per  cent,  (It  has  already 
been  shown  from  the  operations  of  Wertheim,  Doederlein,  Rosthorn 
and  Zweifel  that  the  parametrium  and  the  glands  were  involved  in 
a  large  proportion  of  cases.) 

A  most  complete  radical  operation  is  that  of  Bumm  of  Halle, 
which  is  thus  described  by  Pranz,  of  the  same  clinic  : — ■ 


Bumm's  Radical  Combined  Operation.* 

The  technique  employed  has  been  as  follov/s  :  The  cancer  is 
exposed  in  a  large  vaginal  speculum,  and  the  portio  vaginalis  is 
seized  with  a  hooked  forceps  and  drawn  outwards.  The  cancer 
is  then  scraped  with  a  sharp  spoon  until  no  more  tissue  will  come 
away,  and  a  tolerably  smooth-walled  funnel  is  thus  left,  which  is 
so  thoroughly  cauterized  with  a  Paquelin  that  not  a  drop  of  blood 
or  specific  juice  is  visible  on  the  surface  of  the  growth.  The  infected 
area  and  the  blades  of  the  forceps  are  next  thoroughly  disinfected 
with  alcohol  and  a  one  per  thousand  sublimate  solution.  The  vagina 
is  then  plugged  with  a  strip  of  gauze  soaked  in  the  sublimate  solution. 

The  abdomen  is  opened  (in  the  Trendelenburg  position)  in  the 
median  line,  and  any  intestines  which  may  come  into  view  are 
pushed  back  out  of  the  way  and  carefully  protected.  The  fundus 
of  the  uterus  is  seized  with  volsella,  and  drawn  upwards  and  to  the 
right,  so  as  to  put  the  left  ligamentum  infundibulo-pelvicum  with 
the  spermatic  vessels  on  stretch.  Double  ligatures  are  put  round 
the  ligamentj  and  between  them  it  is  divided  so  that  on  that  side 

*  Fvanz,  Brit.  Gyn.  Journ.,  Aug.,  1903. 


CAscEi!  or  Tin:  rri:iius.  597 


the  two  folds  of  the  ligament  gapt;  apart.  The  finger,  inserted  in 
this  gaping  lissure,  presses  the  folds  of  the  ligament  still  further 
apart,  and  is  thrust  down  to  seek  the  ureter,  which  lies  on  the  pos- 
terior fold  of  the  ligament,  and,  if  sought  there,  may  always  be 
found.  "When  brought  into  view  it  is,  for  the  time,  left  undisturbed. 
The  round  ligament  is  now  ligatured  and  divided,  and  the  peri- 
toneum of  the  broad  ligament  separated  as  far  as  the  attachment 
of  the  bladder  to  the  anterior  cervical  wall.  The  whole  of  the  con- 
nective tissue  of  that  side  of  the  pelvis  is  now  open  to  inspection. 
Deep  down  one  can  trace  the  course  of  the  uterine  artery  the  whole 
way  from  its  origin  at  the  hypogastric  artery  to  the  uterus.  It  is 
ligatured  at  its  origin  and  divided. 

The  ureter  can  then  be  laid  free  right  up  to  its  entry  into  the 
bladder  without  any  bleeding,  and  when  entirely  detached  from 
the  cervix  may  be  displaced,  like  a  free  cord,  to  one  side  towards 
the  wall  of  the  pelvis. 

Exactly  the  same  steps  are  taken  on  the  other  side,  and,  when 
both  ureters  have  been  exposed,  the  peritoneum  of  the  anterior 
cervical  wall  is  divided  transversely  above  the  bladder,  and  the 
latter  separated  by  blunt  dissection  from  the  cervix  and  upper 
part  of  the  vagina.  The  peritoneum  of  the  posterior  cervical  wall 
is  then  also  divided  transversely  above  the  pouch  of  Douglas,  and 
the  folds  of  Douglas  are  ligatured,  and  the  pei-itoneum  with  the 
rectum  is  detached  from  the  posterior  cervical  wall  and  upper  part 
of  the  vagina. 

The  uterus  and  upper  part  of  the  vagina  are  now  quite  free 
before  and  behind,  and  their  only  attachments  are  through  the 
tissue  at  the  sides,  below  the  spot  where  the  ureters  lie  next  to  the 
cervix. 

These  attachments  are  secured  as  near  the  pelvic  wall  as  possible, 
in  Kocher's  clamps,  and  are  then  divided.  When  this  has  been 
done  on  both  sides,  the  uterus  and  upper  part  of  the  vagina  are 
free  all  round,  and  can  be  amputated.  The  vagina  is  opened  in 
front,  and  the  incision  carried  right  round  it.  It  lies  entirely  at 
the  discretion  of  the  operator  how  much  of  the  vagina  is  to  be 
removed.  The  greater  part,  or  even  the  whole  of  it,  can  be  taken 
away  without  any  difficulty. 

The  absolute  arrest  of  all  haemorrhage  is  of  extreme  importance, 
and  after  the  removal  of  the  uterus  every  point  that  is  still  bleed- 
ing is  secured. 

The  next  step  is  to  palpate  the  sides  of  the  pelvis,  especially  along 


598 


DISEASES   OF    WOMEN. 


the  course,  of  the  great  vessels,  and  to  remove  all  glands  that  can 
be  felt,  with  the  connective  tissue  attached  to  them. 

Finally,  the  wounded  surfaces  left  by  the  operation  are  carefully 
shut  off  from  the  peritoneal  cavity,  inasmuch  as  the  anterior  fold 
of  the  broad  ligament  is  united  to  the  posterior,  and  the  vesical 
peritoneum  with  that  of  the  pouch  of  Douglas,  by  a  continuous  catgut 


Fig.  421. — Uteeus  removed  By  Bumm's- Radical  Abdominal  Opekation  foe 
Cancer  (from  Behind).     (Franz.) 

1,  Fundus  uteri;  2,  2,  tubes;  3,  3,  avaries;  4,  4,  parametria;  5,  5,  arterise 
uterinee;  6,  parakolpium  sinistrum;  7,  left  fold  of  Douglas;  8,  posterior 
vaginal  wall. 


suture  beginning  at  the  left  side.  Above  the  catgut  the  serosa 
may  be  stitched  with  a  silk  Lembert  suture  for  extra  security. 
The  abdominal  wound  is  closed  by  continuous  suture  of  the  peri- 
toneum and  muscle  with  catgut,  by  interrupted  silk  suture  of  the 
fascia,  and  by  one  unbroken  aluminium-bi-onze  wire  suture  of  the 
skin. 


CANCER    OF    THE    UTERUS. 


SOI) 


The  last  step  is  to  insert  by  the  vagina  a  short  tampon  in  tlif. 
pelvic  wound.  More  complete  tamponade  has  been  given  up,  for 
the  plug  interferes  with  the  healing  of  the  wound  by  first  intention, 
and  may  even  lead  to  chronic  suppuration,  thrombosis,  and  pyajniia. 
The  vagina  is  loosely  plugged  with  iodoform  gauze. 

Jcssott  draws  tlie  peritoneal  Haps  firmly  down,  keeping  the  ends  ot"  tlio 
forceps  approximated,  and  then  packs  strips  of  iodoform  gauze  tightly  on  each 
side  of  the  flaps  so  as  to  cause  the  peritoneal  surfaces  to  be  brought  into 
accurate  apposition.  Bj'^  adopting  this  practice  he  says  there  is  no  necessity 
to  unite  the  ilaps  l)y  suturing.  Should  the  drainage-tube  be  inserted,  the  flap 
is  drawn  well  down  in  tlic  saiuo  manner. 


Fig.  422. — View  of  the  Caucinoma  fhubi  the  same  Uterus  as  Fig.  421 
(seen  fbom  below). 

1,  Carciuomatous  cavity;  2a,  anterior;  2&,  posterior  vaginal  wall;  3,  portio 
vaginalis  ;  4,  4,  parakolpium. 

Werder's  Operation  (Pittsburg). — ^'  The  metliod  entails  two  preliminary 
stages,  in  which  aU  projecting  cancerous  masses  are  removed  (several  days 
before  the  operation),  and  the  ureters  catheterized  :  and  two  subsequent  stages 
in  which  the  uterus  is  removed.  The  first  of  the  latter  consists  of  the  following 
steps : — Ventral  coeliotomy,  ligation  of  the  round  and  utero-ovarian  ligaments, 
opening  of  the  broad  ligaments,  liberation  of  the  bladder,  dissection  out  and 
freeing  of  the  ureters,  ligation  of  the  uterine  arteries,  freeing  of  the  vagina 
before  and  behind,  removal  of  the  ganglia,  suture  of  the  anterior  peritoneiun 
— drawn  backwards  with  the  bladder — to  the  posterior  peritoneum  (whilst 
the  uterus  is  drawn  strongly  downwards  by  means  of  a  vaginal  forceps  placed 
on  the  cervix),  and  then  closure  of  the  abdomen.  The  second  stage,  per- 
formed at  the  same  sitting  as  the  first,  consists  in  the  division  of  the  ring 
of  vaginal  tissue  which  surrounds  the  cervix  by  the  therrao-cautery,  the 


600  DISEASES   OF    WOMEN. 

extirpation  en  hloc  of  the  uterus  by  the  vagina,  and  the  plugging  of  the 
vagina  with  iodoform  gauze.' 

Schachardt's  Operation. — This  operation  includes  a  vaginal  panhysterec- 
tomy, with  the  addition  of  a  vaginal  incision  extending  from  the  left  fornix 
to  the  introitus,  and  into  the  perineum  by  the  rectum  to  the  sacrum.  Thus 
the  parametria  and  broad  ligaments  are  removed  at  either  side,  the  ureters 
are  exposed,  and  dissected  down  to  the  bladder  before  the  broad  liga- 
ments are  cut.  Schauta,*  who  only  operated  on  14'7  per  cent,  of  cases  of 
cancer,  26"14  per  cent,  only  of  these  being  alive  after  five  years,  states  that 
by  Schuchardt's  method  the  percentage  of  operable  cases  has  been  doubled.  At 
the  same  time  he  is  of  opinion  that  even  with  Wertheim's  or  Freund's  methods, 
and  removal  of  all  the  lymph  glands,  a  large  number  of  cases  must  be  classed 
as  inoperable. t 

Jordan  (Heidelburg),  Doederlein,  Schuchardt,  Olshausen,  A.  Martin,  Winter, 
Kaltenbach,  Fehling,  are  all  advocates  of  the  vaginal  operation  of  hysterec- 
tomy for  cancer.J 

Cancer  of  the  Uterus  in  Pregnancy. — As  regards  the  question  of 
operation  for  cancer  of  the  cervix  during  pregnancy,  the  cardinal 
rule  should  be,  as  Kelly  well  insists,  when  a  radical  operation  is 
possible  to  do  it  without  delay,  in  the  interests  of  the  mother. 
When  this  is  not  feasible,  the  pregnancy  should  be  allowed  to  pro- 
ceed to  term. 

Abdominal  Panhysterectomy  for  Cancer. 

The  operation  known  by  the  name  of  the  '  Ries-Rumpf-Clarke ' 
(Kelly)  involves  the  dissection  of  the  ureters  from  out  the  connective 
tissue,  possibly  the  upper  part  of  the  vagina  and  the  parametric 
tissue.     The  broad  ligaments  and  the  iliac  glands  are  also  removed. 

The  ureters  are  first  catheterized,  either  by  Kelly's  method  or 
by  that  of  Kolischer.  This  is  done  before  the  operation  has  com- 
menced, though  it  may  not  be  possible  to  pass  the  catheter  from 
obstruction  in  the  ureter  from  the  inflammatory  masses  in  which 
it  is  embedded.  The  cervix  is  now  closed  in  the  manner  already 
described,  by  means  of  strong  silk  ligatures.  A  rather  large 
abdominal  incision  is  made,  in  order  to  admit  of  freedom  of  manipu- 
lation during  the  operation.  The  uterus  having  been  exposed,  the 
ovarian  vessels  and  round  ligaments  are  ligated,  clamps  being 
applied  on  the  uterine  side  before  the  round  ligament  is  opened. 

*  Monat.  f.  Geb.  u.  Gyn.,  Feb.,  1902. 

t  Hugo  Efarenfest,  Interstate  Med.  Jr.,  April,  1902. 

X  Thirtieth  Congress,  German  Surg.  Sec,  Berlin,  April,  1901 ;  Winter,  Zeits. 
f.  Geh.  u.  Gyn.,  bd.  xliii.,  s.  509 ;  Hegar's,  Beitrage  z.  Geb.  u.  Gyn.,  bd.  4,  heft 
i.  ;  Schauta  also,  Monats.  f.  Geh.  u.  Gyn.,  bd.,  xv.,  heft  2. 


PLATE   XLV. 


^lusculai- 

fibres  and 

deciduu. 


PiuptureJ 
amnion 

and 
placenta. 


I      f  J 


t 


^ 


Carcino- 
matous 
cervix. 


-J    ^.Sfc'^fc  LL. 


Sectiox  of  Uterus  (Natural  Size)  at  End  of  the  Third  Month  of  Preg- 
nancy -n-iTH  Carcinomatous  Cervix,  showing  Decidua  and  Ruptured 
Amnion.    Operation  Vaginal  Hysterectomy. 
The  section  was  made  in  Halle  when  the  author  was  tliere.  and  given  him 

by  Professor  Bumm.  [To face  j).  600. 


CANCER   OF  THE    UTEliUS.  GO  I 

The  ligatures  are  kept  well  away  from  the  body  of  the  uterus. 
The  uterus  is  now  incised  as  far  as  the  opposite  round  ligament, 
and  a  similar  process  of  ligation  is  carried  out  on  this  side.  We 
proceed  in  the  usual  manner  to  free  the  lower  part  of  the  uterus 
from  the  bladder  and  visceral  peritoneum.  We  next  seek  for  the 
uterine  artery  towards  its  origin  from  the  internal  iliac,  where  it 
lies  somewhat  parallel  to  the  ureter.  The  layers  of  the  broad 
ligament  are  retracted,  and  the  cellular  tissue,  as  far  as  the  pelvic 
floor,  is  separated  by  the  handle  of  the  scalpel.  In  doing  this,  the 
pulsations  of  the  artery  are  felt  for,  and  being  lifted  out  of  its 
bed  it  is  carefully  ligated,  special  pains  being  taken  to  identify 
the  ureter  at  this  point.  Kelly  says,  if  we  catch  the  ureter 
between  the  linger  and  thumb,  its  flat  cordlike  sensation  is  sufiicient 
to  enable  us  to  identify  it."  It  is  carefully  detached  from  the  tissue, 
which  latter  is  dissected  down  to  the  cervix.  The  large  veins  found 
on  the  floor  of  the  pelvis  are  exposed  and  tied  distally  and  proxi- 
mally.  Similar  steps  are  taken  at  both  sides.  Any  enlarged, 
glands  felt  in  the  cellular  tissue  are  dissected  out  along  with  it.  The 
extent  to  which  the  vaginal  vault  is  opened,  and  its  amputation 
completed,  will  depend,  upon  the  position  of  the  carcinoma  and  its 
extent.  'Under  all  circumstances,'  says  Kelly,  'the  amputation 
must  be  made  at  least  two  centimetres  below  the  lower  margin  of 
the  disease.  Before  the  vagina  is  opened,  the  posterior  pelvis  is 
packed  with  gauze,  so  as  to  receive  any  discharge  escaping  from  the 
wound.  The  vagina  is  opened  with  a  Paquelin  knife  at  a  dull  heat, 
its  edges  being  caught,  as  the  section  is  made,  by  artery  forceps. 
By  means  of  an  iodoform  gauze  pack  stuffed  into  it,  and  a  gauze-pad 
bound  round  the  cervix,  contamination  of  the  wound  is  prevented, 
and  during  the  entire  time  the  greatest  care  is  taken  to  prevent  the 
dissemination  of  cancerous  material.  Other  enlarged  glands  are 
now  sought  for  and  have  to  be  removed.  Irrigation  of  the  pelvis 
with  normal  salt  solution  completes  the  operation,  and  a  loose  pack 
is  pushed  through  the  vagina  and  the  opening  into  the  peritoneum, 
so  as  to  support  the  latter. 

Wertheim's  Operation. — In  Wertheim's  method,  which  I  consider 
preferable  to  the  last,  the  abdominal  incision  is  free,  and  after  pro- 
tection of  the  bowel  the  fourth  lumbar  vertebra  is  sought  for,  and 
the  ureter  at  one  side  is  exposed  and  isolated,  the  recognition  being 

*  This  sensation  is  not  always  reliable.  The  suspicious  cord  should  be 
isolated  and  traced  upwards  and  backwards  —  the  duct  isolated,  and  the 
peristalsis  watched  for. 


G02 


DISEASES   OF   WOMEN. 


confirmed  by  the  peristaltic  ureteral  wave.  The  ureters  are  traced 
down  to  the  uterine  arteries,  being  dissected  out  of  any  thickened 
tissues  or  carcinomatous  masses.  This  has  to  be  done  most  care- 
fully, so  as  if  possible  to  avoid  injury  to  the  ureters.  The  uterine 
arteries  are  secured,  and  the  pan-hysterectomy  is  then  proceeded 
with.  The  vaginal  fornix  is  pushed  up  by  an  assistant,  and  opened 
from  above,  the  pan-hysterectomy  being  completed  in  the  usual 
manner.  Before  the  vagina  is  opened,  careful  search  is  made  for 
any  carcinomatous  lymph  glands,  and  these  are  removed,  with  any 
involved  parametric  tissue. 

Martin's  Operation. — Martin  divides  the  operation  as  performed 
by  him  into  four  steps  : — 

1.  Ligaturing  the  base  of  each  broad  ligament,  thus  constricting  the  uterine 

arteries. 

2.  Opening  the  posterior  cul-de-sac  of  the  vagina,  and  the  suturing  of  the 

peritoneum  to  the  vaginal  wall. 

3.  Opening  the  anterior  cul-de-sac,  and  suturing  the  peritoneum  to  the 

vaginal  wall  anteriorly,  by  carrying  the  finger  forwards  at  either  side 


Fig.  423. — Posterior  Cul-de-sac  opened — Suture  applied  to  Peritoneum — 
The  Opening  into  Douglas'  Pouch  aeter  the  Vaginal  Wall  has  been 
sutured  to  the  Peritoneum.     (A.  Martin.) 

of  the  uterus  through  the  opening  made  in  the  posterior  cul-de-sac, 
and  then  opening  the  peritoneum  at  either  side  and  suturing. 
4.  Ligaturing  the  broad  ligaments  and  dividing  the  structures  at  either  side 
of  the  uterus,  between  the  ligatures  and  the  uterine  wall. 


CANCER    OF   THE    UTERUS. 


GOa 


Operation  for  Recurrent  Cancer. — Gushing  has  reported  cases  of 
opei'ation  for  recurrent  cancer  after  hysterectomy.  In  one  the 
bladder  had  to  be  dissected  frei'  from  the  vaginal  tissues.  After 
a  free  dissection,  the  glands  and  the  adjacent  tissues  were  removed, 
and  the  ureter  dissected  out,  free  from  the  broad  ligament,  the 
uterine  artery  tied  at  its  origin,  and  the  whole  of  the  right  side 
of  the  pelvis  cleared  out.  Such  operations,  however,  are  rarely 
satisfactory  in  their  results. 


Extirpation  of  the  Vagina. 

This  operation  may  be  performed  either  by  a  perineal  section, 
and  removal  through  the  perineum  (Olshausen),  or  a  vagino-perineal 
incision  (Diihrssen).  The  entire  vagina  with  the  uterus  and 
ovaries  may  be  thus  removed  (Martin).  By  a  circular  incision  at 
the  introitus  the  vagina  is  detached.  He  covers  the  funnel-shaped 
wound  by  drawing  down  the  peritoneum,  and  attaching  it  to  the 
denuded  surface  at  the  hymeneal  ring. 

Hysterectomy  by  the  Sacral  Method.-  E.  Zuckerkandl  and 
Wolfller  proposed  extirpation  of  the  coccyx  and  the  lower  portion 


Fig.  424. — SrTURrNG  the  Lateral  Structures  in  the  Pelvic  Floor  after 

THE   OPENING   OF   DoUGLAs'   PoUCH.      (A.    MaRTIN.) 

of  the  sacrum.     A  long  and  curved  incision  is  made  towards  the 
left  or  right  side  for  about  ten  centimetres  in  length,  stretching  for 


604  DISEASES   OF    WOMEN. 

about  three  centimetres  above  the  sacro-coccygeal  articulation,  the 
concavity  of  the  curve  being  towards  the  left  side.  The  coccyx, 
when  divested  of  its  periosteum,  is  extii'pated.  The  necessary 
length  of  the  sacrum  is  also  i-emoved  with  as  little  disturbance  of 
the  sacral  nerves  as  possible.  The  rectum  is  drawn  laterally,  and 
Douglas'  pouch  is  opened.  Through  this  space  the  uterus  is  removed. 
The  greatest  care  has  to  be  taken  to  wound  neither  the  bladder  nor 
the  ureter.  Hochenegg  also  recorded  successful  operations,  where 
the  uterus  was  too  large  to  remove  by  the  vaginal  method.  Hegar 
modified  the  operation  by  converting  it  into  an  osteoplastic  one, 
only  temporarily  resecting  the  sacrum  and  coccyx,  and  replacing 
these  after  the  hysterectomy. 

Electro-thermic  Hysterectomy  for  Cancer. — Byrne  removes  the 
whole  uterus,  save  a  thin  shell  at  the  fundus,  with  the  electric 
knife,  reporting  several  successful  results  from  the  operation. 
Downes,  after  high  amputation  of  the  cervix  with  the  electro- 
thermic  knife,  draws  the  fundus  through  a  posterior  vaginal  incision, 
and  applies  the  blades  of  the  angiotribe  to  the  broad  ligaments 
outside  the  ovaries,  then  dividing  the  tissues  on  the  uterine  side  of 
the  angiotribe.  He  has  operated  several  times  by  this  method,  not 
using  a  single  abdominal  ligature.  ISToble  also  has  operated  in  the 
same  manner,  arguing  that  less  blood  is  lost,  that  by  the  sealing 
of  the  lymphatics  there  is  less  risk  of  sepsis,  and  thus  more  of  the 
broad  ligament  is  removed.* 

Downes  argues  f  that  more  tissue  can  be  removed  outside  the 
uterus  by  electro-thermic  hysterectomy  than  by  other  methods  ;  J 
vessels  and  lymphatics  are  rendered  non-absorptive,  and  danger  of 
implantation  is  lessened,  while  a  bloodless  field  is  left  after  operation. 
Downes  uses  three  angiotribes,  with  difi"erent-sized  blades,  varying 
in  width.  The  current  is  under  the  control  of  a  transformer,  and 
arranged  in  the  operating-room  both  "for  the  alternating  and  con- 
tinuous currents.  One  part  of  the  cable  connects  the  current  with 
the  operating-table,  and  another  the  instruments  at  the  edge  of  the 
table.  The  platinum  cautery  blade  of  the  knife  should  be  of  the 
same  amperage  as  will  heat  the  blade  of  the  angioti'ibe,  thus  serving 
as  an  index  of  the  strength  of  the  current,  or  a  meter  may  be 
included  in  the  circuit. 

*  Amer.  Med.,  May,  1902. 
t  Amer.  Gyn.,  Dec,  1902. 

X  See  pages  497-501  for  description  of  hysterectomy  by  means  of  the  electro- 
hsemostatic  angiotribe. 


CHAPTER   XXXIII. 
CHORION-EPITHELIOMA. 

In  1889  Sanger  described  a  highly  malignant  sarcoma-like  growth  of 
the  body  of  the  uterus,  arising  after  an  abortion  in  the  eighth  week. 


-  'jn*tt^ 


Fig.  .42.x — Chokion-epithelioma.     (Haui.tain.) 

Uterus  (full  size).  Posterior  wall  split  open  showing  uterine  cavity,  d,  new 
growth  on  anterior  wall :  b,  blood-clot  attached  to  tumour ;  (m)  uorraal 
uterine  mucosa. 

He    regarded    it   as   a    special   variety  of   tumour  developed    from 


60(3  DISEASES   OF   WOMEN. 

decidual  cells — necessarily,  therefore,  associated  with  pregnancy ; 
and  he  called  it '  deciduoma  malignum.'"*  Sanger's  observations  on 
the  malignant  character  of  these  degenerations  were  followed  by  those 
of  Pfeiffer,  1890,  Chiari,  Miiller,  Gottschalk,  Schmorl,  Kaltenbach, 
and  others.  In  Erance,  Nove-Josserand,  Lacroix,  Paviot,  Jeannel 
and  Beach,  recorded  cases  in  1893,  and  an  able  summary  of  the 
subject  was  written  by  Maurice  Cazhi  in  La  Gynsecologie  (Feb.,  1896). 
Pestalozza,  in  Italy,  recorded  other  cases,  and  an  example  of 
malignant  mole,  in  which  he  recognized  the  chorion-epithelium  as 
the  source  of  the  tumour  tissue,  as  far  back  as  1891. 

Maier,  in  1875,  published  in  the  Archives  of  Virchow  two  observations 
on  tumours  of  the  body  of  the  uterus  composed  of  decidual  tissue.  One 
of  these  cases  was  afterwards  shown  by  Hegar  to  have  died  of  a  malignant 
affection  considered  to  be  cancer  of  the  uterus. 

Sanger  and  Pfeiffer  arrived,  quite  independently,  at  the  same 
conclusions  as  to  the  nature  and  origin  of  the  disease,  and  both 
suggested  the  term  '  deciduoma  malignum  '  as  the  most  suitable  desig- 
nation. In  1893  Sanger  published  a  monograph  on  the  subject, 
and  included  in  it  a  classification  of  all  the  allied  tumours  which 
had  up  to  that  time  been  described.  He  was  mistaken  as  to  the 
origia  of  the  cells  composing  the  growth,  but  to  him  is  primarily 
due  the  recognition  of  the  condition  as  a  specific  malignant  disease 
affecting  the  pregnant  uterus.  It  had  hitherto  been  confounded 
with  other  malignant  affections. 

The  next  landmark  in  the  history  of  the  disease  was  the  publi- 
cation of  Marchand's  work  in  1895.  He  described  for  the  first 
time  the  correct  pathology  of  hydatiform  mole.  He  maintained 
that  deciduoma  resulted  from  a  proliferation  of  both  layers  of  the 
chorionic  epithelium,  and  he  demonstrated  the  close  resemblance 
between  the  characteristic  histological  features  in  simple  and 
maHgnant  mole,  and  between  those  in  the  latter  and  deciduomata. 
Finally,  in  1896,  Aschoff  demonstrated  the  actual  origin  of  a 
deciduoma  from  the  epithelium  of  villi  contained  in  it  (Fig.  427). 
Aschoff  also  helped  to  re-establish  the  opinion  that  both  layers  of 
the  chorionic  epithelium  were  of  fcetal  epiblastic  origin. 

A.  view  formerly  held,  and  still  adhered  to  by  a  few,  is  that  the 
oTowth  is  simply  a  sarcoma  of  the  uterus,  modified  by  the  super- 
vention of  pregnancy.     This  was  the  conclusion  arrived  at  by  the 

*  '  Zwei  aussergewohnliche  Falle  von  .Abortus ' — '  Ueber  Sarcoma  uteri 
deciduo-cellulare.' 


cuoiuox-ErrrnELiOMA.  (;o7 

pathulogicai   comniittec  of  tho    Ohstcibrical   Society   of  London   in 
1896,  but  subsoquently  abandoned  by  its  members.* 

Chorion-epithelioma  in  Males. 

An  interesting  fact  brought  out  at  the  discussion  at  tho  Ob- 
stetrical Society  of  London,  in  1896,  is  that  syncytial  masses,  similar 
to  those  found  in  chorion-epithelioma,  occur  in  malignant  testicular 
growths.  These  growths  are  believed  to  be  of  a  teratomatous 
nature,  i.e.  due  to  the  '  inclusion '  of  an  ovum. 

Schlagenhaufer  has  shown  that  chorion-epithelioma  may  occur 
in  males  in  tumours  of  the  testicle  (teratomata).  These  tumours 
contain  the  elements  of  all  the  three  germinal  layers  in  which 
masses  are  found  which,  if  given  to  a  pathologist  without  infor- 
mation, would  be  diagnosed  as  chorion-epithelioma.  Not  only  do 
they  create  metastasis,  but  they  exhibit  the  pathological  appear- 
ance of  villous  growth  known  as  hydatid  mole.  Fisch  f  regards 
such  teratomas  as  real  embryomas — that  is,  tumours  arising  "  from 
tissues  of  the  developing  foetus  which,  during  development,  have 
been  separated  from  the  normal  aggregation,"  and  he  regards, 
in  common  with  Schlagenhaufer,  the  female  chorion-epithelioma 
as  an  embryoma  in  which  the  segregation  of  embryonic  material 
has  taken  place  during  pregnancy.  That  the  tumour  appears 
for  such  a  length  of  time  as  even  up  to  eight  years  from  the 
last  pregnancy,  has  been  urged  as  an  argument  against  its  foetal 
origin.  We  must,  says  Fisch,  believe  '■'  that  the  main  cause  of  the 
occurrence  of  these  tumours  is  not  the  pregnancy  itself,  but  the 
fact  that  during  a  pregnancy  a  segregation  of  embryonal  material, 
either  of  a  normal  ovum  or  an  abortion,  has  taken  place.  This 
material  need  not  be  derived  from  the  last  pregnancy,  but  may  lie 
dormant,  just  as  the  material  forming  the  other  teratomas  may  lie 
dormant,  for  a  great  number  of  years. 

A  description  of  chorion-epithelioma  will  be  more  readily  appre- 
ciated if  accompanied  by  a  brief  delineation  of  the  physiological 
processes  from  which  a  deviation  gives  rise  to  the  disease.  Recent 
researches  have  considerably  modified  the  views  held  as  to  the  mode 

*  See  discussion  on  J.  H.  Teacher's  paper,  June,  1903.  His  contributions  to 
the  Obstetrical  Society  of  London,  and  the  Journal  of  Obstetrics  and  Gynxcology 
of  the  British  Empire  (the  most  important  that  have  been  made  in  this  country) 
have  been  freely  availed  of  by  the  author,  and  are  more  than  onceiquoted  in  extenso. 
He  is  also  indebted  to  Dr.  Teacher  for  the  photographs  which  have  illustrated 
his  communications. 

t  Amer.  Gyn.,  Jan.,  190.S. 


608 


DISEASES   OF    WOMEN. 


of  attachment  of  the  ovum.  It  is  probable  that,  on  its  adhering  to 
the  mucous  membrane  of  the  uterus,  its  outermost  cells  cause  the 
absorption  of  the  maternal  tissues  with  which  they  come  in  con- 
tact, producing    an   excavation   into  which  the    ovum    sinks.     At 

the  same  time  these  cells  under- 


FiG.  426. — Ovum  of  the  Guinea-pig 
Six  Da'vs  and  Twelve  Hours  and  a 
Half  aftek  Coitus,  almost  com- 
pletely   IMBEDDED    IN    THE    UtEEINE 

Mucous  Membrane. 

The  hole  in  the  uterine  epitlielium  is 
blocked  by  the  outermost  cells  of  the 
ovum,  and  somewhat  contracted.  Its 
edges  are  sharply  defined  from  the 
ovum,  which  is  already  differentiated 
into  outer  and  inner  sets  of  cells.  The 
cavity  around  it  is  formed  by  the  de- 
struction of  a  zone  of  connective  tissue, 
degenerative  changes  extending  into 
a  still  wider  zone.* 


go  rapid  proliferation,  forming 
a  thick  layer,  for  which  Hu- 
brecht  has  suggested  the  term 
trophoblast.  As  the  destruction 
of  the  uterine  mucous  mem- 
brane proceeds,  the  enlarged 
decidual  vessels  are  opened,  and 
the  trophoblastic  cells  creep 
along  the  course  of  the  vessels, 
penetrating  more  deeply  into 
the  uterine  wall  in  such  situa- 
tions than  elsewhere.  Clefts 
appear  in  the  trophoblast, 
which  become  continuous  with 
one  another  and  with  the  in- 
terior of  the  decidual  arteries 
and  veins,  the  walls  of  which 
have  been  destroyed.  Into  and 
across  the  sinuses  formed  by 
the  fusion  of  these  clefts,  pro- 
cesses of  foetal  mesoblast,  carry- 
ing blood-vessels,  project,  and 
as    they    do   so    they  derive    a 


covering  from  the  trophoblast, 
which  becomes  the  epithelium 
of  the  villi  thus  formed.  The 
sinuses  are  therefore  occupied 
by,  and  the  villi  bathed  in,  arterial  maternal  blood,  supplied  directly 
by  branches  of  the  uterine  arteries,  and  flowing  without  the  inter- 
vention of  capillaries  into  the  decidual  veins.  These  spaces  are,  there- 
fore, lined  with,  and  the  villi  covered  by,  cells,  which,  while  rapidly 
proliferating,  have  as  a  function  the  invasion  and  replacement  of  the 
maternal  tissues,  and  the  opening  of  the  vessels  with  which  they  come 
in  contact.    Normally  the  process  ceases  as  the  object  which  it  serves 

*  The  drawing  is  from  V.  Spec,  'Die  Implantation  des  Meerschweinchenies ' 
(Teacher's  paper,  Jour.  Obstet.  and  Gyn.  Brit.  Emp.,  July,  1903). 


CHORION-EPITHELIOMA.  G09 


becomes  effected,  viz,  the  attachment  of  the  frctus,  and  the  pro- 
vision of  a  mechanism  for  the  necessary  interchange  between  the 
maternal  and  f  cetal  circulations.  In  a  small  percentage  of  cases  the 
process  appears  to  run  riot,  and  shows  no  such  tendency  to  cease,  or, 
having  ceased,  again  becomes  abnormally  and  persistently  active. 
In  other  words,  the  chorionic  epithelium,  or,  as  might  even  be  said, 
"  tlie  placenta,"  becomes  the  site  of  malignant  disease. 

Morbid  Anatomy. — At  an   early  stage  of  gestation,   the  meso- 
blastic  stroma  of  the  villi,  containing  the  blood-vessels,  is  enclosed 


C'^?:'t4\, 


Fig.  427. — Section  of  DEcinroMA  Maligxtm  from  the  Corpus  Uteri, 

SHOWING    THE    SAKCOMATOrS   FoRM   OF   TlSSUE. 

Giant  cells  and  small  round  cells,  without  any  definite  arrangement.  In  parts 
the  degeneration  of  the  vessels  is  seen,  the  lumen  limited  by  the  neoplastic 
tissue  itself.  Section  mounted  by  Orthmann,  from  a  case  operated  upon  by 
A.  Martin.     Given  to  the  author  in  Berlin,  1897. 

in  a  double  layer  of  epithelium.     (Fig.  428  shows  this  admirably, 
although  it  is  from  a  tumour.) 

(1)  An  inner  single  layer  of  cubical  cells  having  clear  protoplasm 
and  round  or  oval  vesicular  nuclei  of  relatively  large  size,  mode- 
rately rich  in  chromatin,  and  showing  a  well-marked  intra-nuclear 
network  and  nucleolus.  This  is  known  as  Langhan's  layer,  and  the 
cells  as  the  individual  cells. 

(2)  Enclosing  that,  and  separating  it  from   the  maternal  blood 

2  R 


610 


DISEASES   OF   WOMEN. 


in  the  intervillous  space,  is  the  syncytium-  -a  layer  of  protoplasm 
in  which  no  definite  cell  boundaries  are  recognizable.  The  proto- 
plasm has  an  opaque  appearance,  and  takes  the  usual  contrast 
stains  somewhat  deeply.  The  nuclei  are  generally  smaller  than 
those  of  the  Langhan's  layer,  oval  or  more  elongated  in  shape, 
solid,  and  stain  more  deeply. 

The  syncytium  frequently  spreads  out  into  buds,  which  may  even 
be  detached  from  the  main  layer,  and  lie  apart  as  multi-nucleated 
2;iant  cells  free  in  the  maternal  blood. 


*vS^15|| 


•^■f?!. 

■■»&■: 


■     93. 


Fig.  428. — Small  Poetion  of  Villus,  showing  the  Origin  of  the  Tumour 

FROM  THE  Epithelium.     (Teacher.) 

The  continuity  of  the  various  cell-formation,  with  one  or  other  layer  is  obvious. 

Karyokinetic  figures  are  numerous  in  the  Langhan's  layer  cell  masses. 

Here  and  there  the  Langhan's  layer  spreads  out  into  masses  of  con- 
siderable size.  These  occur  in  the  intervillous  spaces  (forming  cell- 
knots),  but  are  best  developed  at  the  attachments  of  villi  to  the 
decidua.  At  these  points  they  form  a  layer,  several  cells  deep, 
between  the  tip  of  the  connective  tissue  core  and  the  tissue  to 
which  it  is  attached.  In  the  cell-knots  and.  masses  at  the  tips  of 
vilU  all  forms  intermediate  between  the  typical  individual  cells  and 
the  syncytium  have  been  described.  The  cells  of  which  a  chorion- 
epithelioma  is  composed  are  derived,  as  has  already  been  indicated. 


CnORION-EPTTHELIOMA. 


Gil 


from  the  chorionic  epithelium,  and  may  closely  resemble  one  or 
other  of  the  forms  which  have  just  been  described.  The  cells  of 
the  growth  are,  however,  of  great  variety,  and  many  have  become 
so  modified  that  little  resemblance  remains. 

The  most  typical  forms  are — 

(1)  Multi-nucleated  masses  of  protoplasm,  derived  from  the  sync- 
tium  (Plasmodia  or  syncytia)  of  various  shapes  and  sizes,  in  which 
no  definite  cell  boundaries  are  recognizable.     These  are  frequently 


Fig.  429. — Vacuolated  Syncytitim  with  Masses  of  Langhan's  Larger 
Elements  embedded  ik  it.    (Teacher.) 

To  the  left  the  uterine  tissue  is  infiltrated  with  epithelial  wandering  cells. 
The  leucocytes  present  in  numbers  are  small  in  size  compared  with  the 
cells  of  the  tumour. 

riddled  with  vacuoles  which  may  contain  fluid  blood.  The  nuclei 
are  generally  small,  oval,  dense,  and  stain  uniformly  and  deeply 
with  the  ordinary  chromatin  stains  ;  but  not  infrequently  other 
types  are  seen,  more  especially  large,  clear,  vesicular  nuclei,  which 
have  a  well-marked  intra-nuclear  network  and  one  or  more  nucleoli, 
and  which  stain  comparatively  lightly. 

(2)  Individual  well-defined  mono-nucleated  cells,  which,  in  a  case 


612 


DISEASES   OF    WOMEN. 


containing  villi,  are  seen  to  be  derived  from  the  Langhan's  layer 
(Figs.  428  and  430).  These  usually  form  masses  of  some  size, 
intimately  united  within  the  foregoing.  In  the  youngest  stage 
they  are  small  polyhedral  cells,  closely  packed  together,  and  have 
no  connective  tissue  stroma  between  them.  The  nuclei  are  round 
or  oval,  clear,  vesicular,  have  a  well-marked  intra-nuclear  network, 
and  stain  moderately  deeply.  The  protoplasm  is  scanty,  clear, 
finely  granular,  and   stains   very    lightly.     Frequently   masses   of 


Fig.  430. — Cell  Mass,  showing  the  Lakge  Decidoa  Cell-like  Elements 

AND     InTEEMEDIATE     FoEMS     BETWEEN     THE     LaNGHAN'S    LaTEE    AND     THE 

Syncytium.    (Teachee.) 

Many  of  the  individual  cells  contain  several  nuclei.     The  mass  is  surrounded 
by  blood  and  thrombi. 

these  cells  lie  inside  the  large  syncytia,  or  show  a  border  of  syncytium, 
which  may  be  so  thin  as  to  resemble  endothelium.  Strands  of 
syncytium  also  stretch  in  among  the  individual  cells  in  a  highly 
irregular  fashion. 

(3)  Laz'ge  cells,  sometimes  mono-nucleated,  sometimes  multi- 
nucleated, some  of  which  present  a  resemblance  to  decidual  cells, 
while  others  are  identical  with  the  multi-nucleated  giant  cells  which 


Cl/O/i  /0.\-f:  I-  /  TIfJ'J  fJOM  A. 


013 


occur  in  the  decidiui  scrotina.  These  are,  in  some  parts,  arranged 
in  cell  masses  without  intoi-\euing  tissue  stroma ;  in  other  parts 
they  are  iiililtrating  and  destroying  adjacent  tissues  after  the  manner 
of  sarcoma  (l^^ig.  431). 

The  tumour  contains  neither  connective  tissue  stroma  nor  blood- 
vessels of  its  own,  though  the  irregular  destruction  of  uterine  tissue, 
caused  by  tongue-like  processes  which  penetrate  deeply  into  it,  may 


Fig.  431. — Typical  Massks  of  ('hokiox-epithklioma  invading  thk 
Utekine  Muscle.     (Teacher.) 

The  tumour  tissue  is  distinguished  by  its  darker  sliade.  The  remains  of 
uterine  muscle  among  the  tumour  processes  produces  a  sort  of  alveolar 
structure.  The  dark  masses  with  many  nuclei  are  the  syncytium.  Some 
of  its  detached  masses  simuhite  hypertrophied  muscle  fibres. 


give  a  roughly  alveolar  appearance  (Fig.  431).  As  the  tumour 
extends  the  centre  degenerates,  and  in  a  growth  of  any  size  the 
bulk  may  consist  of  necrotic  or  degenerated  tissue  mixed  with  blood- 
clot.  This  point  assumes  practical  importance  when  tissue  removed 
by  curetting  is  being  examined  for  diagnostic  purposes. 

It  is  probably  not  a  rare  occurrence  in  normal  pregnancies  for  a 
portion  of  a  villus  or  of  cliorionic  epithelium  to  become  detached, 


614 


DISEASES   OF   WOMEN. 


and  to  be  carried  on  by  the  blood-stream  into  the  maternal  veins. 


Fig.  432.    (Haultain.) 
F,  necrotic  area ;  C,  cellular  area  of  activity ;  Y,  villi. 


Fig.  438. — Area  of  Invasion.     (HArLTAiN.) 
Both  varieties  of  malignant  elements  (C>ia  small  vessel  and  surrounding 

tissues. 


CHOU  lON-EPJ  THKLIOM.  I . 


G15 


Such  a  fragment  urdiuarily  disappears,  but  in  rare  instances  develops 
into  a  growth  having  all  the  chuiacteristics  of  chorion-epithelioma, 
and  there  results  a  case  of  the  disease  in  which  the  primary  tumour 
is  situated  away  from  the  placental  site.  When  the  primary  tumour 
develops  at  the  placental  site,  the  detachment,  escape,  and  subse- 
quent development  of  such  portions  into  secondary  tumours,  is  the 
usual  sequence  of  event.  It  will  be  conNcnient  here  to  discuss  the 
pathological  relation  which  chorion-epithelioma  bears  to  certain 
allied  growths,  ^\llich  frequently  reader  its  diagnosis  difficult  or 
uncertain. 

(1)  Simple  hydatiform  mole,   which   is   essentially   the  result  of 


Fig.  434. — Bhaxching  Multixccleatkd  Pp.oTOPLA.'^inc  PiiOCEssEs  free  tx 
Blood  Spaces,     x  400.    (HArLXAiN.) 

excessive  proliferation  of  the  epithelium  investing  the  Adlh.  There 
may  be  hypertrophy  of  the  enclosed  mucous  (embryonic  connective) 
tissue,  but  it  is  not  a  necessary  feature,  and  the  accumi;lation  of 
fluid  within  the  villi,  or  their  hypertrophied  portions,  which  imparts 
to  them  the  appearance  of  translucent  cysts,  does  not  result  from  it. 

(2)  Malignant  hydatiform  moles,  which  resemble  the  simple  moles 
in  structure,  but  in  which  the  epithelium  invades  the  maternal 
tissues,  as  it  does  in  true  chorion-epithelioma,  penetrating  along 
the  vessels  and  giving  rise  to  metastatic  tumours,  which  may  contain 
villi. 

The  simple    tumour   may,   however,    become  malignant,    and    in 


616 


r)ISEA8ES   OF IW OMEN. 


the  malignant  form  hydatiform  villi  constitute  every  possible  pro- 
portion  of  the    growth.      They   may,   by  their   aggregation,  form 

masses  of  considerable  size,  be  few 
or  scattered.  In  the  metastatic 
nodules  they  are  apt  to  be  absent, 
as  in  pure  chorion-epithelioma. 

Etiology.  —  Pregnancy  is  the 
only  recognized  predisposing  cause. 
The  majority  of  cases  follow  an 
abnormal  pregnancy,  such  as  when 
an  abortion  occurs  or  a  mole  is 
present,  more  especially  the  latter. 
Chorion-epithelioma  may  occur  at 
any  stage  of  reproductive  life,  and 
its  frequency  at  any  given  period 
approximately  corresponds  to  the 
frequency  of  births. 

Statistics  of  Survival  after  Operation 
— The  Occurrence  of  Metastases — Tlie 
Nature  of  Last  Pregnancy,  and  the  Ages 
of  the  Patients. — Teacher  has  collected 
189  cases  of  chorion-epithelioma  up  to 
1903.  Of  99  cases  he  has  tabulated 
63  are  reported  under  the  head  of  '  re- 
covered ' — that  is,  about  two-thirds  of 
the  whole.  The  longest  periods  at 
which  such  reports  were  recorded  after 
operation  were,  eight  years,  1  ;  five 
years,  1 ;  four  years,  1  ;  three  and  a  half  years,  1 ;  two  and  a  half  years,  4  ; 
two  years,  1  ;  under  two  years  and  over  one,  6 ;  one  yeai',  6.  Thus  we  see 
that  the  records  of  recovery,  with  the  exception  of  these  21  cases,  were  all 
taken  at  short  periods  of  time — some  few  months  at  the  outside — when  it 
was  not  possible  to  judge  of  the  permanency  of  the  cure.  All  these  cases 
were  operated  upon  before  the  sj^mptoms  had  lasted  more  than  a  few  months 
— ^in  many  after  a  few  weeks.  The  occurrence  of  metastasis  is  noted  in  19  of 
the  99  cases.  From  his  table  of  189  cases  we  gather  the  particulars  of  the 
last  pregnancy.  There  were  66  instances  of  mole  ;  there  were  49  abortions, 
and  42  normal  births  recorded. 

Looking  at  the  ages  of  these  patients,  we  find  that  of  those  recorded  63 
occurred  between  the  ages  of  twenty  and  thirty,  59  between  thirty  and  forty, 
37  between  forty  and  fifty,  7  between  fifty  and  sixtj^,  and  3  were  noted  at  the 
respective  ages  of  seventeen,  eighteen,  and  nineteen ;  the  oldest  age  recorded 
was  fifty-five.* 

*  McOann  (Jour.  Obstet.  Gyn.  Brit.  Emp'.,  Mar.,  1903)  reported  a  case  of  this 


Fig.  435. — Isolated  Mass  of  Syn- 
cytium IN  A  Blood-vessel  of  the 
Uterus,  attached  to  the  Wall, 
AND  IN  Process  of  forming  a 
Metastatic  Pouch. 

From  V.  Spee,  '  Die  Implantation 
des  Meerschweinchenies.' 


PLATE  XLVI. 


Detieneraling  Blood 
Clot  and  h'ibrin. 


Section  of  Tumour,  including  Cyst. 

(Halliday  Groom.) 


»"^aters:oGiS=ns,L-Uii,  Edtc  - 


To  face  page  6i£ 


PLATE  XLVlA. 


Section  of  Tumour. 

(Halliday  Croom.) 


GeoWkterstoaiSoDsXiih.Editt. 


TofcUmu  Piatt . 


PLATE   XLVII. 


Section  through  Lung,  showing  Metastatic  Deposits. 

(Halliday  Groom.) 


Geo  "Waters toni.  Sens  X'ilii,  Edm. 


To  follow  Piatt  XI.Vl 


ciioiiiO};-i:riTiii:iJOM.\.  617 

Symptomatology. — At  a  variable  period,  averaging  about  six 
weeks,  after  a  Jiormal  labour,  an  abortion,  or  the  removal  or  ex- 
pulsion of  a  mole,  a  woman  becomes  liable  to  attacks  of  profuse  and 
recurrent  luximorrhage.  After  a  brief  interval  a  foul  and  sometimes 
sanguineous  discharge  appears,  and  masses  of  blood-clot  and  shreds 
of  tissue  are  expelled,  Anasmia,  which  is  associated  with  progressive 
emaciation  and  weakness,  becomes  rapidly  and  intensely  developed. 
Rigors  are  not  uncommon.  They  are  generally  attributable  to 
septic  absorption,  but  may  indicate  the  occurrence  of  metastasis. 
To  these  symptoms  are  superadded  those  arising  from  the  presence 
of  metastatic  growths  in  such  organs  of  the  body  as  the  lungs  or 
brain.  Death  usually  supervenes  within  six  or  seven  months  unless 
averted  by  operation. 

Metastasis. — The  accompanying  plates,  for  which  I  am  much  indebted  to  Sir 
Ilalliday  Groom,  iUustrate  a  case  of  deciduoma  malignum  recorded  by  him. 
The  patient  Avas  a  multipara,  forty-four  years  of  age.  Six  years  previously, 
she  had  had  an  abortion,  from  which  time  till  four  months  before  admission 
to  hospital  she  had  menstruated  regularly.  For  four  months  immediately 
prior  to  admission,  she  had  not  menstruated,  but  had  suffered  from  a  foul 
Icucorrhocal  discharge.  For  a  few  weeks  before  admission  she  had  noticed 
a  swelling  in  the  lower  abdomen ;  her  attention  was  drawn  to  this  by 
spasmodic  attacks  of  pain. 

When  first  seen,  the  patient  was  emaciated,  and,  on  examination,  a  hard 
uniform  tumour  was  found  stretching  half-way  from  pubis  to  umbiUcus. 
On  the  left  labium  there  was  a  small  tumour,  about  the  size  of  a  walnut, 
which  was  taken  for  a  Bartholinian  retention  cyst.  As  it  was  causing  great 
discomfort,  it  was  incised,  when  it  was  found  to  be  solid,  and,  on  microscopic 
examination,  proved  to  be  of  the  nature  of  deciduoma  malignum.  The 
patient  died  of  lung  complication  before  radical  treatment  could  be 
employed. 

The  tumour  (Plate  XLVI.)  weighed  7  lbs.  7  oz. 

Between  the  tumour  and  the  bladder  was  a  cyst  filled  with  clear  fluid 
(Plate  XLVI.). 

Metastatic  deposits  were  found  in  lung  (Plate  XLVII.),  vagina,  brain,  and 
kidney. 

There  are  sevei'al  clinical  features  little  understood.  '  For  in- 
stance,' as  Eden  remarks,*  '  we  are  quite  unable  to  explain  why 
these  growths  vary  so  greatly  in  malignancy ;  why  those  cases  in 
which  villi  are  found  in  the  tumour  should  be  less  malignant  than 

affection  in   a   multipara   aged  53,  who  had   borne  ten  children.     Periodical 
hsemorrhage  was  the  principal  symptom.     The  uterus  was  enlarged  to  the  size 
of  a  three  months'  pregnancy.     Vaginal  hysterectomy  proved  the  case,  as  shown 
by  careful  microscopical  examination,  to  be  of  chorion-epithelioma. 
*  Obstetrical  Society  of  London,  June  3,  1003. 


618     .  DISEASES   OF   WOMEN. 

others ;  why  cases  in  which  the  primary  growth  is  in  the  vagina  are 
less  malignant  than  the  uterine  cases ;  why  metastases  should  dis- 
appear after  the  removal  of  the  primary  growth  alone ;  and,  lastly, 
why,  in  one  remarkable  case  recently  recorded  by  Fleischmaun, 
partial  removal  of  the  primary  growth  should  be  followed  by  dis- 
appearance of  the  remainder  and  complete  recovery.'  * 

Diag-nosis  and  Treatment. — Chorion- epithelioma  should  be  sus- 
pected if  bleeding  follow  the  expulsion  of  a  vesicular  mole,  or  return 
after  curettage  for  imperfect  expulsion  of  the  ovum.  In  these 
instances  a  thorough  digital  examination  of  the  interior  of  the 
uterus  should  be  made.  A  valuable  indication  may  be  afforded  in 
malignant  disease  by  the  profuse  nature  of  the  haemorrhage  attend- 
ing the  performance  of  curettage.  In  those  rare  cases,  already 
referred  to,  in  which  the  primary  growth  is  situated  deeply  in  the 
wall  of  the  uterus,  or  in  some  distant  organ  of  the  body,  uterine 
hasmorrhage  is  absent. 

It  must  not  be  forgotten  that  simple  retention  of  placental  tissues 
may  give  rise  to  symptoms  like  those  of  deciduoma,  and  that  the 
risk  of  performing  needless  radical  operation  is  considerable. 

Case  of  Recurrent  Haemorrhage  after  Molar  Abortion — Symptoms 
Simulating  those  of  Deciduoma  Malignum.j 

The  following  case  shows  the  difficulty  of  diagnosis  as  well  as  prognosis  iu 
certain  forms  of  prolonged  discharge  associated  with  molar  pregnancy.     A 

*  In  regard  to  metastases  due  to  chorion-epithelioma,  Zagorjanski  of  Kissel 
(Archiv.  f.  Gyn.,  bd.  Ixvii.,  heft  2)  reports  cases  in  which  the  lung  symptoms 
disappeared  after  the  removal  of  chorion-epitheliomatous  nodules  from  the 
vagina.  Agreeing  with  Pick,  he  arrives  at  these  conclusions : — Such  emboli 
have  been  observed  in  the  lungs,  brain,  kidneys,  uterine  musculosa,  but  most 
frequently  in  the  vagina  (seven  times  out  of  eleven).  No  instance  of  the  spon- 
taneous cure  of  a  chorion-epithelioma  by  autonomic  elimination  with  the  placenta 
or  mole  has  been  demonstrated;  on  the  other  hand,  the  possibility  of  the  spon- 
taneous retrogression  of  chorion-epitheliomatous  growths  cannot  be  altogether 
rejected  (cases  cured  without  auy  operation  or  after  a  very  incomplete  one). 
For  chorion-epithelioma  to  be  malignant  it  is  essential  that  the  physiological 
resistance  of  the  tissues  of  the  body  to  invasion  should  be  diminished  or 
destroyed;  the  restoration  of  that  resistance  puts  an  end  to  the  growth  of  the 
tumour.  In  this  way,  in  case  of  chorion-epithelioma  of  the  vagina  and  lungs, 
after  the  removal  of  the  vaginal  growth  the  lungs  may  recover  spontaneously, 
and  this,  in  spite  of  the  negative  result  given  by  the  sputum,  we  must  suppose 
to  have  taken  place  in  the  case  above  mentioned.  During  pregnancy  nodules  of 
chorion-epithelioma  in  other  parts  of  the  body  than  the  uterus  and  tube,  point 
to  the  presence  of  an  hydatid  mole.  Every  case  of  primary  extra-uterine  chorion- 
epithelioma  after  normal  labour  hitherto  reeorded  has  had  a  fatal  termination. 

t  Reported  by  the  author,  Brit.  Gyn.  Jour.,  1902. 


GIIORION-KI'ITIIi:!.  10  MA .  619 

liatieiit,  aj^ed  twLMity-tlirce,  siilVercd  from  peisistoiiL  sickness  witli  aggravated 
pains  in  tlio  liypogaslriiun,  witli  pain  in  tlio  right  groin  and  down  the  corre- 
sponding tiiigli ;  liad  beiMi  one  year  and  eiglit  months  married.  There  was  a 
liistory  of  previous"  dehcacy  and  some  apical  trouble  of  botli  hnigs,  witii  dys- 
menorrha'a,  consequent  upon  a  retroflocted  uterus  with  conical  cervix.  For 
these  troubles  she  had  been  under  treatment,  and  the  uterus  was  incised, 
dilated,  and  curetted.  Shortly  after  marriage  she  suffered  from  metrorrhagia 
and  a  brown  discharge,  which  persistently  lasted  from  one  period  to  another. 
On  examination,  the  cervix  was  found  soft  and  the  uterus  enlarged,  with  a 
sanious  discharge  from  the  canal.  She  had  just  passed  over  the  time  for  a 
period  when  there  was  a  severe  attack  of  htemorrhage,  followed  by  the  pro- 
trusion of  a  molar  mass  from  the  os  uteri.  The  uterus  was  dilated  and 
curetted,  a  quantity  of  foetid  molar  dchrin  being  removed.  It  was  subse- 
quently proved,  however,  that  the  entire  mass  was  not  removed,  for  on  the 
fifth  day  there  was  some  bleeding,  and  on  examination  a  substance  was 
found  filling  the  cervix,  which  was  again  dilated,  and  the  uterus  completely 
emptied  of  more  of  the  same  debris.  It  was  wiped  out  with  chromic  acid, 
and  a  few  times  subsequently  with  ichthyol  and  iodized  phenol.  As  there 
was  a  recm-rence  of  hjemorrhage,  about  three  months  subsequently  I  again 
dilated  the  uterus,  curetted  it,  and  applied  chromic  acid.  The  patient  re- 
gained her  strength  and  put  on  flesh.  Exactty  a  year  from  the  date  of  the 
first  operation  pain  and  bleeding  again  commenced,  and  the  uterus  was  sensi- 
tive to  touch.  I  found  a  small  fungoid-looking  growth  protruding  from  the 
OS.  She  was  now  again  curetted,  and  the  growth  removed.  It  was  decided 
to  perform  hysterectomy  should  this  growth  or  the  curettings  prove  to  be  of 
a  malignant  nature.  Mr.  Targett  made  a  most  careful  examination  of  the 
tissue  removed,  but  there  was  nothing  of  the  chorion-epithelioraatous  or 
sarcomatous  natin-e  in  it.  A  year  subsequent!}^  I  heard  from  her.  She  had 
gained  28  lbs.  in  weight  and  was  quite  well,  though  for  some  time  in  the 
interval  she  had  had  a  recurrence  of  her  old  discharge. 

The  discovery  of  soft  vegetating  masses  would  tend  to  confirm 
the  diagnosis.  What  appear  coagula  may  in  reality  be  neoplastic 
masses  into  which  blood  has  infiltrated.  The  facility  with  which 
the  finger  may  perforate  the  uterus  has  to  be  borne  in  mind. 
Curettage  should  be  performed,  and  all  material  removed  should 
be  placed  at  the  disposal  of  an  expert  pathologist  for  examination ; 
and  the  diagnosis  should  rest  upon  the  clinical  as  well  as  on  the 
microscopical  evidence.  An  early  diagnosis  may  be  impossible,  and 
the  truth  may  be  ascertained  in  the  post-mortem  room.  In  other 
instances,  by  adopting  the  measures  enumerated  above,  the  disease, 
when  present,  may  be  diagnosed  with  reasonable  certainty,  and 
when  discovered,  there  is  but  one  recognized  form  of  treatment, 
and  that  is  total  extirpation  of  the  uterus. 


CHAPTER  XXXIV. 
TUBERCULOSIS  OF  THE  FEMALE  GENITALIA. 

MoRGAGNi  in  1744,  through  a  post-mortem  examination,  was  the 
first  authority  to  draw  attention  to  genital  tuberculosis  in  the  case 
of  a  patient  who  died  of  tubercular  peritonitis.  In  the  early  part  of 
the  nineteenth  century  (1831)  Senn  and  Raynaud,  and,  later,  Louis 
(1843)  also  recorded  the  presence  of  tubercular  lesion  in  the  genitalia. 
In  the  fifties,  Thiry,  Jeil,  Paulsen,  and  Kiwisch  ;  later  on,  Brouardel 
(1865),  Cohnheim  (1879),  Verneuil  (1883),  and  Hegar  in  1886,  all 
proved  that  tuberculosis  of  the  genitalia  was  not  such  a  rare  affection 
as  it  had  been  previously  thought. 

Frequency  of  Occurrence. — A.  Martin  said,  in  his  report  on  the 
Rome  Congress,  in  1892,  "  the  female  genital  organs  share,  much 
oftener,  than  has  been  hitherto  supposed,  in  the  infection  by  the 
tubercle  bacillus,  which  may  begin  and  develop  in  any  segment  of 
the  female  genital  apparatus."  Murphy  gives  the  following  statistics 
bearing  on  the  relative  proportion  of  cases  of  tubercle  of  the  genitalia 
in  women  who  were  tuberculous. 

Niraias  and  Christoforis  found  one  case  in  every  12  necropsies  on 
tuberculous  women  ;  Schram  found  one  case  in  34  cases,  Posner 
one  in  35,  Mosler  one  in  40,  Kiwisch  one  in  40,  and  Cornil  one  in 
every  50  to  60  cases. 

Merletti,  in  6000  necropsies  at  Parma,  found  that  tuberculosis 
was  the  cause  of  death  in  1360.  In  205  of  these  the  genitals  were 
involved;  in  males  34  (2*41  per  cent.),  in  females  172  (12-6  per 
cent.). 

Hansemann  (cited  by  Yeit),  however,  in  7000  necropsies  at  the 
Friedrichshain  Hospital,  Berlin,  found  450  cases  of  tuberculosis  in 
women  (6-5  per  cent.).  In  only  18  of  these  (4  per  cent.)  were  the 
genitals  involved. 

*  I  must  acknowledge  my  indebtedness  in  this  chapter  to  J.  B.  Murphy,  of 
Chicago,  and  the  comprehensive  summary  of  the  entire  subject  embraced  in  his 
presidential  address  before  the  Chicago  Surgical  Society,  October  13, 1903.  Also 
to  Comyns  Berkeley's  paper  in  the  Journal  of  Obstetrics  and  Gyiisecology  of  the 
British  Empire,  Jan.,  1903. 


TUBERCULOSIS   OF   THE   FEMALE   GEXTTALLA.  621 

Out  of  1600  pieces  of  tissues,  from  the  gynsecological  clinic  at 
Griefswald,  which  were  examined  for  tubercle  bacilli,  the  latter 
were  found  in  24  (Martin). 

Etiology. — -There  are  some  points  which  are  of  interest  in  the 
etiology  and  pathogeny  of  the  disease. 

Hereditary  Influences. — Amann*  considered  that  we  must  admit 
that  genital  tuberculosis  in  infants  has  a  congenital  origin,  the  glands 
being  first  affected,  and  through  them  the  circulation,  though  later 
on  infection  comes  from  the  air  passages,  or,  more  rarely,  from  the 
digestive  canal  and  mesenteric  glands,  finding  their  way  by  erosion 
of  the  blood-vessels  into  the  circulation.  Gottschalk  regarded  a  case 
of  tuberculosis  of  the  adnexa  as  primary  and  hereditary,  because 
three  years  after  pan-hysterectomy  was  performed  by  the  vagina  no 
recurrence  of  the  disease  had  occurred.  The  patient,  aged  32,  was 
a  ^drgo  intacta.  The  tubercular  nature  of  the  affection  was  proved 
by  culture  and  inoculation.  The  father  was  tuberculous.  Xo  tuber- 
cular lesions  were  found  elsewhere.  The  tubes  and  ovaries  were 
affected  as  well  as  the  uterus. f  Amann  had  a  case  in  which  tuber- 
culosis of  the  genitalia  was  proved  to  arise  through  an  affection  of 
the  bronchial  glands,  neither  peritoneum  nor  intestine  being  affected. 

Sex. — Amann  also  considered  that  the  proportion  of  female  subjects 
to  male  affected  with  tuberculosis  was  20  per  cent,  of  the  former 
to  3  per  cent,  of  the  latter.  Hyperplasia,  chronic  inflammatory 
changes,  and  the  puerperal  state  increased  the  disposition  to  the 
affection. 

Coition. — Both  Verneuil  and  Cohnheim  regarded  coition  as  a 
probable  starting-point  in  some  cases  of  the  infection.  Fernet  traced 
in  two  well-verified  instances  the  tubercular  condition  to  coitus,  and 
different  authorities  have  shown  the  presence  of  the  bacUlus  in  the 
semen  of  tuberculous  men.  Murphy  reports  a  case  in  which  direct 
transmission  by  coitus  also  occurred,  though  he  has  seen  so  many 
cases  of  tuberculosis  of  the  epididymis  with  tubercle  bacilli  in  the 
urine  and  seminal  discharge  in  married  men  without  the  wife 
becoming  affected,  that  he  concludes  that  other  conditions  are 
necessary  for  the  development  of  tuberculosis  in  the  female  genital 
tract.  On  the  other  hand,  should  tuberculosis  of  the  cervix  extend 
to  the  vagina,  and  not  involve  the  Fallopian  tubes  or  ovaries,  such 

*  Fourth  International  Congress  of  Obstetrics  and  Gynaecology,  Rome. 
Lucina,  Oct.,  1902. 

fAiihiv.f.  Gyii..hi..  Ixx.,  s.  74.  Gottschalk  (ibid.,  bd.  xx.,  s.  74)  surmises 
that  the  source  of  tlie  tuberculosis  may  have  been  the  semen. 


622  DISEASES   OF    WOMEN. 

limitation  of  the  infection  Emanuel  considers  shows  that  the  disease 
has  been  primarily  conveyed  during  coitus.  The  finger  may  convey 
the  disease,  so  may  the  sound  or  other  instrument.  The  important 
clinical  and  prophylactic  bearing  on  this  latter  fact  is  obvious.  At 
least  we  are  justified  in  the  conclusion  that  intercourse  with  a 
consumptive  husband  is  fraught  with  danger  to  the  wife.  The 
possibility  of  his  being  a  cause  of  direct  infection  to  her  can  be 
pressed  with  emphasis  in  those  sad  cases  where  infatuation  and 
afiection,  despite  remonstrance,  still  prompt  I'ash  determination  to 
marriage,  or  husband  and  wife  to  occupy  the  same  bed. 

The  Blood  as  a  Vehicle  of  Infection. — Veit  also  considers  that 
the  genesis  of  tuberculosis  is  from  above,  and  rarely  from  below ; 
that  it  may  occur  from  infection  from  the  blood,  as  well  as  through 
the  lymphatics. 

According  to  Kleinhans  there  are  three  arguments  in  favour  of 
infection  by  means  of  the  blood  current  : — 

1.  The  existence  of  tuberculosis  in  the  genitals  following  tuber- 
culosis of  the  lungs,  with  no  intermediate  foci. 

2.  The  frequent  localization  of  tuberculosis  on  the  site  of  the 
placental  attachment. 

3.  The  transmissibility  of  the  bacilli  from  the  mother  to  the  foetus. 
To  these  Veit  adds  the  sudden  eruption  of  acute  general  miliary 

tuberculosis,  which  has  been  many  times  noticed  to  succeed  the 
existence  of  a  markedly  circumscribed  focus. 

Schottlander,  having  injured  the  fimbriated  edges  of  the  Fallopian 
tube  in  rabbits,  injected  the  tubercle  bacilli  into  the  circulation,  and 
found  that  the  abdominal  end  of  the  wound  became  infected.  He 
concludes  that  conveyance  of  the  tuberculosis  through  the  blood 
is  common,  more  so  than  that  through  the  uterus ;  and  Amann, 
having  regard  to  the  comparatively  poor  supply  of  the  parts 
between  the  uterine  artery  below  and  the  ovarian  artery  above, 
considers  that  this  relatively  poorer  supply  of  blood  to  this  area 
may  have  an  etiological  significance  in  the  presence  of  tubercle 
here. 

Infection  through  the  Peritoneum. — In  considering  the  causation 
of  genital  tuberculosis,  the  experiments  of  Pinner  have  a  special 
significance.  He  showed  that  fijie  portions  of  cinnabar  or  lamp- 
black introduced  into  the  peritoneal  cavity  traversed  the  tubes, 
and  found  their  way  through  the  uterus  and  into  the  vagina.  This 
would  explain  certain  cases  of  infection,  but,  on  the  other  hand,  it 
has  to  be  remembered  that,  while  the  peritoneum  is  untouched,  the 


TUBERCULOSIS   OF   THE    FEMALE    GENITALLA.  623 

genitalia  are  frequently  affected,  and  vice  versa.  Of  this,  however, 
there  can  be  no  doubt — when  the  Fallopian  tubes  are  affected  the 
peritoneum  and  bowel  are  frequently  also  tuberculous.  All  observa- 
tions of  tubal  tuberculosis  go  to  prove  this  correlation. 

From  Murphy's  experiments  on  monkeys  it  is  clear  that  the  infec- 
tion does  travel  from  the  peritoneum  to  the  sub-peritoneal  glands. 
Murphy's  experiment  on  a  monkey  showed  '  that  the  tubercular 
process  may  extend  deep  into  the  muscular  layer  of  the  uterus  into 
the  body  of  the  muscle  coat  from  the  peritoneal  side,  but  it  does  not 
completely  traverse  the  muscle  coat.  This  would  indicate  that  it  is 
possible  that  the  uterine  mucosa  might  become  infected  from  the 
peritoneum  by  direct  transmission  through  the  uterine  wall.  He 
was  unable  to  find  any  report  of  a  post-mortem  showing  this  con- 
dition in  the  human  female,  nor  was  a  case  reported  in  which  a 
primary  tuberculosis  of  the  uterine  mucosa  penetrated  the  muscularis 
in  the  peritoneum.  So  that  he  considers  it  is  fair  to  assume  that 
this  is  at  least  not  a  frequent  route  of  transmission,  either  from 
the  peritoneum  to  the  mucosa,  or  vice  versa.' 

Testicular  Contact  and  Seminal  Infection. — Cases  of  tuberculous 
infection  arising  from  the  contagion  of  testicular  tuberculosis  have 
been  recorded  by  Pfannenstiel  and  Prochownik,  and  various  experi- 
ments have  been  performed  to  test  the  relationship  between  general 
tuberculosis  and  tubercle  of  the  genitalia  by  Landouzy,  Maffucci, 
Gaertner,  Spano,  Peraire,  Popoff",  and  others.^  From  such  experi- 
ments it  seems  clear  that  semen  taken  from  a  tuberculous  patient, 
and  injected  into  the  peritoneal  cavity,  will  cause  tuberculosis  ;  that 
tubercular  cultures  injected  into  the  saphenous  vein  of  animals 
infected  the  testes ;  that  bacilli  may  be  transmitted  from  parent  to 
foetus  through  inoculation  of  the  testes  ;  that  injections  of  tubercular 
culture  into  the  vagina  of  animals  will  cause  infection  of  the  uterus. 
Popoff",  however,  from  the  result  of  his  experiments  concluded  that 
there  must  be  a  preceding  trauma  in  order  to  infect  the  genitals,  and 
that  tuberculosis  following  traumatism  remains  localized  in  the 
genital  apparatus  and  its  lymph  glands. 

Infection  from  without. — Extensive  experiments  by  Marie 
Gorovitz  have  confirmed  these  conclusions,  and  shown  that  tuber- 
culosis may  reach  the  vagina,  the  iliac,  or  lumbar  glands,  from  the 
uterus,  and  also  directly  invade  the  lumbar  glands,  as  well  as  the 
peritoneum.  It  is  noteworthy  that  gonorrheal  abrasions,  the  trau- 
matisms of  the  puerperal  state,  and  operative  procedures  have  been 

*  Murphy,  loe.  cit. 


624  DISEASES   OF    WOMEN. 

shown  to  lead  to  tuberculous  infection.  Even  catheterism  of  the 
uterus  has  been  reported  by  Diihrssen  to  lead  to  infection  of  the 
tube  and  peritoneum.  The  same  consequence  has  followed  on  opera- 
tions on  tubercular  cystomata.  This  author  has  also  reported  infection 
following  the  injection  of  milk  from  a  tuberculous  cow. 

Relative  Frequency  of  Infection. — Statistics  prove  that  the  order 
of  frequency  with  which  the  different  organs  are  affected  is,  Fallo- 
pian tubes,  body  of  uterus,  ovaries,  cervix  uteri,  vagina,  and  vulva. 
Corayns  Berkeley,  *  from  an  examination  of  the  post-mortem  records 
of  the  Brompton  Hospital  for  Consumption,  from  1880  to  1902, 
during  which  period  the  genitalia  had  been  carefully  examined, 
states  that  in  798  autopsies  performed  on  females  who  died  of 
tuberculosis,  in  62  (7-7  per  cent.)  the  genitalia  were  affected,  and 
the  order  in  which  this  occurred  was.  Fallopian  tubes,  80'6  per  cent. ; 
body  of  uterus,  29-0  per  cent.;  ovaries,  22-5;  cervix,  6*4;  vagina, 
6'4 ;  vulva,  0. 

Ehrenfest,  quoting  Kundrat,  and  Penrose,!  concludes  that  tuber- 
culosis is  present  in  from  8  to  18  per  cent,  in  all  cases  of  inflammatory 
disease  of  the  uterine  appendages. 

Tuberculosis  of  the  Genitalia  in  Children. 

Age. — Already  attention  has  been  drawn  to  the  presence  of 
tuberculosis  in  children,  and  the  importance  of  rectal  exploration, 
as  urged  by  Carpenter,  in  the  examination  of  the  adnexa,  Demme 
has  reported  cases  aged  respectively  seven  and  thirteen  months. 
'  Children,'  Murphy  states,  '  have  primary  tuberculosis  manifested 
only  in  the  external  genitalia.'  Schenk  has  reported  a  case  of 
ulceration  of  the  external  genitalia  in  a  child  4^  years  old.  The 
child  had  had  tubercular  playmates,  and  he  surmises  that  the  infection 
was  conveyed  by  the  fingers.  Karajan  reports  vulva  tumours  in  a 
child  two  years  of  age. 

Murphy  quotes  Maas,  who  draws  special  attention  to  the  com- 
parative rarity  of  tubal  tuberculosis  in  children  as  compared  with 
adults.  He  could  find  but  eight  cases  in  medical  literature  of  very 
young  children  in  whom  tuberculosis  of  the  tube  was  present. 

Howard  Kelly  has  reported  several  cases  of  tuberculosis  in 
children. 

George  Carpenter,  of  the  Evelina  Hospital  for  Children,  who  has 

*  Jour.  OUtet.  and  Gyn.  Brit.  Emp.,  Jan..,  1903. 

t  Arch.f.  Gyn.,  vol.  Ixv.,  No.  1. ;  'Text-book  of  Diseases  of  Womeu,  1901.' 


TUBERCULOSIS  OF  THE  FEMALE  GENITALIA.  G25 


had  exceptional  opportunities  for  the  examination  of  the  female 
genitalia  in  children,  writes  thus : — '  My  records  of  tuberculous 
disease  of  the  female  genitalia  have  been  gained  by  the  use  of  com- 
bined rectal  and  bimanual  examinations  during  life,  and  also  in  the 
post-mortem  room. 

'  (a)  In  a  child,  aged  9  years,  the  Fallopian  tubes  were  enlarged 
and  caseous.  Tuberculous  extension  had  taken  place  from  the 
peritoneum,  and  they  had  been  invaded  at  their  fimbriated 
extremities. 

'  (b)  In  a  gii'l,  aged  4  years,  the  ovaries  were  matted  to  the 
Fallopian  tubes,  the  extremities  of  which  showed  cavities  filled  with 
caseatiug  material ;  she  had  tuberculous  intestinal  ulceration, 
together  with  tuberculous  brain  tumours,  but  no  peritonitis. 

'  (c)  In  a  girl  of  7  years  was  found  an  enlarged  uterus,  the  right 
Fallopian  being  the  diameter  of  a  lead  pencil ;  there  was  a  tuber- 
culous mass  the  size  of  a  pigeon's  egg  just  above  the  base  of  the 
sacrum. 

'  {d)  A  girl,  aged  7  years,  who  suffered  from  tuberculous  ascites, 
had  a  rounded  tumoiu',  three  inches  in  length,  and  the  thickness  of 
the  index  finger,  attached  to  the  fundus  of  the  uterus.  This  tumour 
subsequently  disappeared.     She  has  grown  into  a  healthy  woman. 

'  (e)  In  a  child,  aged  2  years  and  2  months,  there  was  con- 
siderable peritoneal  thickening  in  the  hypogastric  region  and  its 
neighbourhood  ;  the  left  ovary,  which  was  found  to  be  enlarged,  was 
adherent  to  the  thickened  peritoneum.  This  child  had  tuberculous 
glands  in  the  neck  and  an  enlarged  spleen. 

'  (/)  In  a  child,  aged  2-^  years,  there  was  a  tuberculous  mass 
involving  the  right  lumbar,  iliac,  and  the  hypogastric  regions. 
The  left  ovary  and  Fallopian  tube  were  healthy,  but  the  growth 
had  invaded  the  tube  and  ovary  on  the  cox'responding  side. 

'  {g)  In  a  child,  aged  14  months,  there  was  a  hard  lump  occupying 
the  umbilical  and  hypogastric  regions,  and  the  right  ovary  was 
connected  with  it. 

\{li)  In  a  girl,  aged  six  years,  there  was  a  tuberculous  mass  in 
the  right  inguinal,  lumbar,  hypogastric,  and  umbilical  regions, 
together  with  typical  omental  thickening.  The  uterus  was  normal. 
Passing  from  it  to  the  right  was  a  cmdy  tube,  the  size  of  the 
little  finger,  and,  on  being  hooked  down,  an  oval  tumour  was  felt, 
which  was  an  enlarged  ovary.  The  left  Fallopian  tube  was  not 
so  enlarged,  and  it  did  not  curl;  its  corresponding  ovary  was  not 
enlarged.' 

2  S 


626  DISEASES   OF   WOMEN. 

In  three  other  cases  recorded  by  Carpenter,  aged  respectively 
3  years,  14  months,  and  1  year,  the  adnexa  were  also  affected,  and 
the  characteristic  '  lumpishness ' — the  term  he  uses  to  express  the 
appearance  and  the  feel  of  tubercular  masses  involving  the  adnexa — 
was  present.'  He  has  had  no  experience,  clinical  or  pathological, 
of  primary  tuberculous  affection  in  children. 

Diagnosis. — Speaking  generally,  the  diagnosis  of  tubercle  of  the 
genitalia  will  depend  upon  («)  a  careful  local  examination  of  the 
vulva,  vagina,  and  portio  vaginalis,  assisted  by  a  bi-manual  ex- 
amination of  the  uterus  and  adnexa  under  anaesthesia,  (b)  a  micro- 
scopical and  bacteriological  examination  of  some  portion  of  the 
affected  tissues  which  are  within  reach  and  can  be  removed  by  either 
the  knife,  scissors,  or  curette ;  (c)  a  similar  examination  of  the 
fragments  removed  after  curettage  of  the  uterine  cavity  ;  (d)  the 
presence  of  tuberculosis  in  other  organs  of  the  body  ;  (e)  the  physical 
characteristics  of  the  surfaces  affected,  the  appearances  of  the 
ulcerated  parts,  and  of  the  tubercular  ulcers,  as  to  their  colour  and 
the  nature  of  the  granulations ;  (/)  the  duration  of  the  disease  and 
the  subjective  symptoms  which  have  accompanied  it. 

Sellheim  considers  that  '  certainty  in  the  diagnosis  depends  upon 
local  examination.  Independent  of  the  characteristic  peculiarities 
to  be  met  with  in  the  exploration  of  the  abdomen,  much  information 
may  be  gained  by  the  recognition  of  tuberculosis  of  the  pelvic  peri- 
toneum, which  almost  invariably  accompanies  similar  disease  of  the 
genitals,  and  which,  as  pointed  out  by  Hegar,  may  be  detected  on 
internal  examination,  by  nodules  that  are  almost  pathognomonic. 
These  nodules  are  found  chiefly  upon  the  posterior  surfaces  of  the 
ligamenta  sacro-uterina,  and  fi'equently  the  tube  has  assumed  the 
form  of  a  rosary  in  which  the  nodules  are  of  an  extremely  hard 
consistence.  The  presence  of  a  nodule  in  the  pars  uterina  is  a 
reliable  sign  of  tubercular  disease.  Microscopical  examination  of 
the  mucosa  of  the  uterus  is  always  necessary  in  case  of  tuberculosis 
affecting  the  tubes  or  the  pelvic  peritoneum,  as,  apart  from  its 
diagnostic  importance,  disease  of  the  uterine  mucosa  may  modify 
the  prognosis  and  treatment.  Using  all  these  methods,  Sellheim, 
dissenting  from  the  opinions  expressed  elsewhere,  considers  that 
tuberculous  disease  of  the  female  genital  organs  may,  in  most  cases, 
be  diagnosed.'  * 

The  diagnosis  of  tuberculosis  of  the  vulva,  vagina,  uterus,  and 
tubes,  is  referred  to  under  the  different  headings  named. 

*  Brit.  Gyn  Jour.,  Nov.,  1902. 


TUBERCULOSIS   OF   THE   FE.)fALE  GENITALIA.  Cyll 


Differentiation  from  Carcinoma. 

Charles  liyall  (Cancer  Hospital)  has  furnished  me  with  notes  of 
three  cases  in  which  tuberculosis  of  the  peritoneum  and  adnexa  was 
mistaken  for  malignant  disease.  In  one,  the  patient,  aged  35, 
presented  all  the  appearances  associated  with  advanced  cancer,  a 
tumour  being  quite  fixed  in  the  pelvis  and  incorporated  with  the 
uterus.  Though  regarded  as  incurable,  she  was  kept  under  observa- 
tion, and  as  the  tumour  became  smaller  an  exploratory  incision  was 
made.  This  revealed  extensive  peritoneal  tuberculosis,  and  a 
dermoid  cyst  of  one  ovary. 

In  another  case,  mahgnant  disease  of  the  adnexa  was  diagnosed. 
A  nodular  growth,  adherent  to  the  uterus,  was  fovmd,  which,  on 
examination  through  the  pouch  of  Douglas,  appeared  to  be  cystic. 
Operation  revealed  extensive  peritoneal  tuberculosis,  a  dermoid  cyst 
of  one  ovary,  and  the  pelvis  full  of  caseous  material.  The  age  of 
this  patient  was  H. 

In  the  third  instance,  the  woman  was  aged  45.  A  nodular  and 
irregular  mass  occupied  the  left  fornix  and  Douglas'  pouch.  The 
growth  was  very  hard  and  fixed.  Exploration  i*evealed  extensive 
pelvic  peritoneal  tuberculosis,  and  a  small  papillomatous  cyst  of  the 
left  ovary. 

In  each  of  these  cases  the  emaciation,  the  constitutional  symptoms, 
and  the  physical  characters  of  the  growth,  favoured  the  idea  of 
malignancy.  In  none,  however,  does  there  appear  to  have  been 
any  characteristic  discharge,  nor  was  the  uterine  cervix  or  canal 
affected,  while  the  absence  of  pain  and  haemorrhage  should  have 
made  the  diagnosis  of  malignancy  at  least  doubtful.  All  three 
show  the  need  for  remembering  the  similarity  in  the  constitutional 
effects  of  both  affections.  I  have  myself  opened  the  abdomen  under 
similar  conditions,  finding,  not  carcinoma,  as  I  expected,  but  wide 
tubercular  infections. 

Tuberculosis  of  the  Vulva. 

There  is  somewhat  of  a  conflict  of  opinion  as  to  the  rarity  of 
tuberculosis  of  the  vulva.  Some  cases  of  lupus  have  been  reported. 
Matthews  Duncan  first  described  the  condition  which  he  termed 
'lupus  of  the  vulva.'  This  included  chronic,  painless,  hypertrophic 
states  of  the  vulva,  without  infection  of  the  neighbouring  glands,  yet 
liable  to  various  degrees  of  ulceration.     Thin,  from  his  pathological 


628  DISEASES   OF    WOMEN. 

examination  of  some  growths  submitted  to  him  by  Duncan, 
supports  this  view,  pointing  out,  however,  that  the  microscopic 
appearances  are  quite  different  from  those  found  in  lupus  vulgaris. 
There  was  small  cell  infiltration  beneath  the  epithelium,  and  blood- 
vessels ran  straight  to  this  part.  Fibrous  tissue  was  found  in  all 
stages  of  development. 

Both  Hutchinson  and   Malcolm  Morris  regarded  these  cases  as 
having  a  syphilitic  origin.     I  had  one  such  typical  case  as  described 
by   Duncan.     I  could  clearly  trace  a  syphilitic  history.     Shaving 
away  the  growth,  I  applied  Paquelin's  cautery,  and  the  part  healed 
permanently.     According  to  Berkeley,  Whitridge  Williams   could 
only  find  records  of  three  cases  of  true  tubercle  up  to  1894,  those  of 
Deschamps,  Chiari,  and  Zeigbaum  *  one  case  only,  that  of  Risck, 
having  occurred  since.     In  these  instances  the  tubercle  bacilli  were 
found.     The  case  of  Kelly,  in  which,  after  excision  of  the  diseased 
area,  which  included  the  greater  part  of  the  external  genitals,  he 
covered   the   parts    by  flaps    taken   from  the  vaginal  wall,  is  not 
referred    to   by   Berkeley.     The    patient  was    aged   55,   the  vulva 
was  ulcerated,  the  disease  involved  the  vestibule  and  central  portion. 
Some  bacilli  were  discovered,  and  characteristic  granulations,  with 
scattered  tubercles  through  the  deeper  tissues,  were  present.    Alto- 
gether, Murphy  quotes  fifteen  cases  in  which  the  vulva  was  afiected, 
including,  besides  those  mentioned,  cases  reported  by  Cay  la,  Viattel, 
Montgomery,  Davidsohns,  and  Klittner.    The  latter  cured   a  little 
girl  of  six  years  who  suffered  from  tubercular  bronchial  catarrh. 
There  was  induration  of  the  right  labium,  with  ulceration  and  small 
ulcers  over  the  mons  veneris  and  upper  part  of  the  left  labium. 
The  diseased  structures  were  excised,  and  these  and  the  ti'ibutary 
lymph  glands  showed  typical  tubercular  lesions.     All  this,  however, 
only  proves  that  tubercular  disease  of  the  vulva  is  of  extremely  rare 
occurrence. 

Esthiomene. — Murphy  considers  that  esthiomenic  ulcer,  lupus 
and  rodent  ulcer,  should  be  included,  but  it  is  doubtful  if  the  true 
esthiomene  {Iddiw,  '  to  eat '),  and  cases  of  rodent  ulcer,  should  be,  at 
least  in  a  large  proportion  of  the  instances  in  which  they  are  met, 
I'egarded  as  of  a  tubercular  character. 

Characters. — Tubercular  ulcers  of  the  vulva  are  usually  shallow, 
of  irregular  shape,  sometimes  oval  or  round,  extending  slowly,  having 
granular  surfaces,  the   granula:tions  being   either   semi-translucent 

*  Johns  liopldns  Hospital  .Reports,  vol.  iii.  p.  85. 
t  See  chapter  on  Aflections  of  the  Vulva. 


Tl'BEECULOSIS   OF   THE  FEMALE   GENfTALlA.  6'i9 

or  of  a  yellowish  colour.  The  margins,  though  occasionally  sharply 
defined,  are  often  irregular  and  ragged.  A  crust  occasionally 
covers  the  base  of  the  ulcer.  The  ulceration  may  linally  lead  to 
destruction  of  parts  of  the  labia  and  fourchette,  and  extend  into 
the  perineum.  Under  these  circumstances  the  appearance  of  the 
ulceration  is  not  unlike  that  of  epithelioma  or  chancroid.  Should 
there  be  proliferation  of  tissue,  both  nodules  and  polypi  may  be 
present  (Murphy),  and  the  clitoris  enlarged  so  as  to  resemble  that 
affected  with  elephantiasis.  It  is  important  to  remember  that  the 
lymph  glands  are  not  involved  for  a  long  time,  and,  clinically,  the 
very  slow  progress  of  the  disease,  added  to  careful  microscopical 
and  bacteriological  examination  of  portions  of  tissue  removed,  will 
serve  to  contirm  the  diagnosis. 

Poeverlein,*  in  a  case  which  was  diagnosed  as  sarcoma,  removed 
from  the  inner  surface  of  the  right  labium  of  a  woman,  aged  49, 
a  tumour  the  size  of  a  five-shilling  piece.  There  was  no  ulceration. 
Microscopical  examination  proved  it  to  be  tubercular.  It  would 
appear  to  be  the  only  case  on  record  in  which  no  ulceration  was 
present. 

Tuberculosis  of  the  Vagina. — So  far  it  appeal's  that  only  one 
case  of  primarij  vaginal  tuberculosis  has  been  recorded  (Murphy). 
Bierfreund  found  a  tubercular  ulcer  in  the  vagina,  the  only  focus  in 
the  body.  Therefore  the  tuberculous  infection  is  conveyed  either 
from  above,  from  the  uterus,  or  from  the  vulva  (very  rare)  from 
below.  Giel  found  that  in  45  cases  of  tubercular  disease  of  the 
uterus,  the  vagina  was  only  affected  in  3,  Springer  collected 
statistics  of  cases  occurring  in  the  Frauenklinik  in  Prague  during 
twelve  years,  and  gave  the  source  of  the  disease  as  arising  twice 
from  the  blood,  three  times  from  the  uterus,  once  from  the  Pallopian 
tube,  and  once  from  the  intestine  (Berkeley).  The  possibility  of 
the  urine  being  the  channel  of  the  infection  is  suggested  by  him. 
These  sources  of  infection  embrace  all  those  given  by  Amann,  with 
the  exception  of  direct  infection  from  without. 

Varieties. — It  may  l^e  of  a  miliary  or  ulcerative  character.  The 
ulcers  are  surrounded  by  a  zone  of  infiltration,  in  tlie  centre  of 
which  is  the  characteristic  greyish  ulcer  with  a  rather  clearly  cut 
edge,  at  times  filled  with  caseous  matter,  under  which  lie  the  grey 
or  yellow  granulations  of  which  its  base  is  composed.  Extension  of 
the  ulceration  may  proceed  in  the  direction  of  the  rectum  or  the 
bladder.     Under  all  circumstances  the  progress  is  very  slow. 

*  Hegar's  '  Beitraege,'  bd.  viii.,  h.  1. 


630  DISEASES   OF   WOMEK. 


Tubercle  of  the  Portio  Vaginalis. 

Frequency. — The  portio  vaginalis  is  also  a  rare  site  of  infection. 
Of  163  cases  mentioned  by  Murphy  (including  27  necropsies  of 
tuberculous  women  by  Doran),  there  were  only  8  cases  in  which 
the  cervix  was  affected.  That  it  may  appear  here  as  a  primary 
focus  is  clear  from  cases  recorded  by  Agello,  Michaelis,  Emanuel, 
Williams,  Matthews,  Lewers,  Driessen,  Beyea,  and  others. 

It  is  noteworthy  that,  as  Fraenkel  has  shown,  tuberculosis  may 
be  present  in  the  adnexa  and  cervix  while  the  fundus  remains  free 
of  the  infection.  On  the  other  hand,  the  portio  may  be  free  while 
the  Fallopian  tubes  are  affected. 

Varieties. — Murphy  divides  tubercle  of  the  portio  into  ulcera- 
tive, papillary,  miliary,  and  '  bacillary- catarrhal.'  He  asks,  with 
A.  Martin,  '  Is  it  the  tenacious  secretion  of  the  cervical  mucosa,  or, 
as  Vassmer  believes,  the  thick  epithelial  layer  here  which  opposes 
the  penetration  of  the  bacilli  ? '  It  is  curious  also  that  negative 
results  have  followed  searches  for  bacilli  (Merletti)  in  the  uterine 
secretion.  Yet  inoculation  with  these  same  fluids  has  proved 
tuberculosis  to  be  present.  This  makes  it  clear  that  the  inoculation 
test  giving  a  positive  proof  of  the  presence  of  tuberculosis  does  not 
in  itself  establish  the  fact  of  the  genitalia  being  affected,  as  the 
infection  may  come  from  the  peritoneum. 

In  the  ulcerative  form  we  have  single  or  multiple  ulcers,  deeper 
than  erosions,  and  of  varying  size  and  extent.  In  the  impillnry 
tuberculosis  we  have  proliferating  fungous  masses,  underneath 
wMch  are  the  beds  of  tubercular  granulations.  A  close  re- 
semblance to  carcinoma  may  cause  these  to  be  confounded  with 
this  latter  affection.  In  the  miliary  form  there  is  the  character- 
istic dissemination  of  miliary  tubercles,  scattered  here  and  there 
throughout  the  stroma  of  the  portio,  and  over  the  mucous  surface. 
Ulceration  may  occur,  but  it  is  not  certain.  The  hacillary -catarrhal 
variety  is  limited  to  the  surface  epithelium,  and  the  glands,  which 
latter  may  be  filled  with  caseous  material  containing  numerous 
bacilU  (Schutte). 

Microscopic  Appearances. — Murphy  thus  summarizes  the  micro- 
scopical appearance  of  cervical  tuberculosis  :  — 

'  As  regards  microscopic  appearances,  we  find  many  variations  in 
cervical  tuberculosis,  depending  on  the  stage  of  the  process  and  the 
form  of  the  disease.  Tuberculosis  of  the  cervical  mucosa  manifests 
tself  primarily  by  a  proliferation  and  metaplasia  of  the  surface  and 


TI'nERCrLOSrs:   OF    THE    FE.VAr.E   (!ENTT.\r.[A.  631 

glandular  opitlielium.  The  glaud  lumen  becomes  occluded  Ijy  di\i.sion 
of  the  lining  cells.  In  cases  like  the  one  of  Alterthum,  where  the 
microscopic  appearances  closely  resembled  carcinoma,  a  large  number 
of  slides  must  be  examuied  until  the  tubercular  nature  is  positively 
demonstrated.  In  the  beginning  of  mild  forms  of  cervical  tuber- 
culosis, the  infiltration  of  small  cells  may  be  limited.  After  the 
glandular  lunien  is  obliterated  by  proliferation  of  the  lining  cells, 
the  glands  appear  as  solid  columns.  As  the  disease  progresses  the 
metaplastic  cells  show  retrogressive  changes,  finally  ending  in 
necrosis  and  caseation.  Giant  cells  are  only  occasionally  encoun- 
tered in  the  gland  proper.  According  to  Emanuel,  the  cervical 
glands  and  stroma  may  also  hypertrophy  in  the  tubercular  process, 
and  resemble  the  section  of  an  adenoma. 

'  As  the  degeneration  of  the  epithelium  progresses,  granulations 
take  its  place,  and  the  cervical  mucosa  is  now  covered  with  granu- 
lation tissue  in  which  only  glandular  debris  may  be  recognized. 
Giant  cells  and  tubercles  are  now  observed.  More  or  less  hyper- 
trophy of  the  connective  tissue  is  seen  in  nearly  all  forms,  coexisting 
in  the  more  chronic  forms  with  areas  of  caseation  and  necrosis.  In 
the  papillary  type  the  fungous  growths  are  made  up  of  granula- 
tions and  new-foi-med  connective  tissue,  in  which  are  blood-vessels, 
giant  cells,  and  tubercles,  in  addition  to  diffuse  epithelioid  cell 
formations.' 

Primary  Tuberculosis  of  the  Cervix. — Hauschka  operated  on  a 
case  in  which  there  was  a  hard  tumour  the  size  of  a  hazel-nut 
in  the  cervix  with  prolongations  into  the  canal.  Vaginal  pan- 
hysterectomy proved  it  to  be  primary  tuberculosis  of  the  cervix.'"' 

Tuberculosis  in  the  Fundus  Uteri. — 'Merletti,  in  172  cases  of 
genital  tuberculosis,  found  well-marked  lesions  of  the  uterus  in  7-5. 

'  Yassmer,  reporting  6  cases  of  tuberculosis  involving  the  uterus, 
in  -0  of  which  diagnosis  was  established  by  the  curette,  states  that 
they  appeared  at  the  clinic  within  ten  months. 

'  Stolper,  in  34  necropsies  on  tuberculous  women,  found  uterine 
tuberculosis  in  3  ;  and  Wolff,  in  1 7  similar  necropsies,  found  uterine 
tuberculosis  in  3  also. 

'  Cullen,  in  eighteen  months,  diagnosed  6  cases  fi'om  the  clinic ; 
and  in  Martin's  clinic  at  Greifswald,  where  the  mucosa  is  examined 
as  a  matter  of  routine,  in  some  1500  cases  tuberculosis  was  found 
24  times.' 

Symptomatology. — When  any  woman  presents  herself  suffering 
*  Wiener.  Klin.  Wchns.,  1901,  Xo.  51. 


632 


DISEASES   OF   WOMEN. 


from  endometritis  of  a  chronic  nature,  attended  by  a  discharge 
which  is  more  of  the  leucorrhceal  than  the  ordinary  and  character- 
istic discharge  of  chronic  endometritis,  the  possibility  of  tubercular 
infection  must  be  kept  in  mind.  Should  the  leucorrhoea  resist 
treatment,  and  after  a  temporary  cure  again  recur,  and  there  be 
any  evidence  of  tuberculosis  elsewhere  in  the  body,  this  suspicion 
will  be  strengthened — the  more  so  if  the  character  of  the  discharge 


Fig.  430.— TcBEEcrLAE  Disease  op  the  Utekcs.     (Egbert  Baexes.) 
The  cervis  unaffected ;  the  Fallopian  tuhes  were  filled  with  tnhercular  deposit. 

changes  and  assumes  somewhat  of  a  caseous  appearance.  If  a 
bi-manual  examination  be  made  under  such  circumstances,  and 
the  adnexa  be  found  to  be  enlarged,  and,  further,  if  there  be  signs 
of  tubercular  peritonitis,  our  suspicions  are  verified,  and  careful 
examination  of  any  discharge  for  bacilli  should  be  made,  or  enough 
of  tissue  obtained  by  curetting  for  tlie  same  purpose,  as  thus  alone 


TrnEnrrr.osr'^  or  the  female  riEXTTALiA. 


633 


can  a  certain  ilia,i,'nosis  bo  arrived  at.  No  clinical  symptoms 
differentiate  tuljorcular  disease  of  the  fundus  ut(!ri  from  other 
forms  of  disease  in  this  situation. 

Diagnosis  of  Tubercle  of  the  Uterus. — The  diagnosis  of  tubercular 
disease  of  tlu'  cervix  is  by  no  means  easy,  so  similar  are  the  obj(!ctive 
signs  to  other  ulcerative  conditions  of  the  portio,  and  the  discharges 
which  accompany  these.  Whereas  in  carcinoma  there  is  greater 
irregularity  and  depth  in  tlie  affected  surfaces,  more  frequent  and 
profuse  bleeding,  greater  fcetor  and  more  pain,  there  is  less  sensi- 
tiveness to  examination,  and  the  rather  typical  granulation  bed  of 


^^//'•)'»?1^S 


Fig.  437.— Tuberculosis  of  the  Cervix  (Expeeimextal).    (After  Cornil.) 

57  diam.     a,  villi  of  the  arbor  vitse  ;  b,  depression  between  two  villi ; 
c,  tubercular  granulation. 

tuberculosis  is  absent.  In  tuberculosis  the  surface  is  more  regular 
and  less  ragged,  bleeding  is  absent  or  less  severe,  fo8tor  is  not  so 
marked  as  in  epithelioma  (this  possibly  being  due  to  the  absence  of 
haemorrhage),  and  the  progress  of  the  disease  is  much  more  pro- 
tracted than  in  carcinoma.  But  the  only  conclusive  tests  are  the 
detection  of  the  miliary  tubercles  and  of  the  tubercle  bacilli. 
(Whitacre.) 

Associated  with  the  advancing  invasion  of  the  muscular  structures 
are  the  changes  which  precede  it  in  the  endometrium.  There  is  cell 
proliferation  in  the  glandular  elements — '  the  cells  assume  a  cuboidal 


634 


DISEASES   OF   WOMEN. 


shape,  and  the  nucleus  moves  towards  the  centre  ; '  the  gland  lumen 
is  encroached  on  and  obliterated.     Coincident  chancres  occur  in  the 


Fig.  438.— ExPEEiMEyTAL  TuBEEcrLOsis.     (Coenil.) 

t.  connectire  tissue,  containing  numbers  of  round  cells  ;  c,  giant  cell ;  'p,  papillte 
and  superficial  vegetations  ;  e,  fissure  in  tuberculous  tissue  with  epithelial 
cells  similar  to  those  lining  a  tuberculous  follicle.  Adjoining  this  latter  is 
portion  of  a  glaud  with  its  epithelial  lining,  the  cells  of  which  are  thickened 
and  aggregated  (35  diam.). 

epitheKum,  which  proliferates  and  finally  degenerates.     Giant  cells 
are  occasionally  present.    Caseous  material  covers  the  endometrium. 


Fig.  439. — IJTEErs,  Tubes,  Begad  LiGAaiESTS   axu   Ovaeies   studded  with 

TUBEECLES — COIN'CIDEXT   EPITHELIOMA   OF   THE   CeE^TX.      (HoWAED   KeLLY.) 

CI  nat.  size.) 

and  gradually  tills  the  cavity  of  the  fundus,  when  the  muscular 
structure    gives  way   before  ulceration    and    degenerative  process. 


TUBERCULOSIS   OF    THE   FEMALE   CENITALIA.  035 


The  caseous  mass  breaks  dovni  into  pus,  ,^ving  rise  to  the  charac- 
teristic purulent  discharge  of  this  variety.  Meanwhile  the  canal  is 
occluded  by  the  ca.ieous  material,  and  a  hydroinetra  or  pyometra 
may  result.  The  frequency  with  which  the  uterus  is  infected  from 
the  tubes  explains  the  common  invasion  of  the  cornua  of  the  uterus. 
Relation  to  Menstruation  and  Pregnancy. — It  is  thought  that 
menstruation  changes  offer  an  obstacle  to  the  process  of  tuber- 
culosis, as  it  is  more  frequently  present  in  the  uterine  cavity 
before  puberty  and  after  the  menopause.  It  appears  that  multi- 
para are  the  more  susceptible  to  the  infective  changes  in  the  par- 
turient and  vascular  supplies,  such  as  rupture  and  thrombus,  and 
consequent  alterations  in  the  vessels  are  believed  to  favour  tlie 
tuberculosis  process. 

Amann  and  others  confirm  the  view  that  it  is  rare  for  genital 
tuberculosis  of  the  uterus  to  be  transmitted  from  the  peritoneum  or 
bowel,  or  indeed  from  the  lymphatics.  The  infection  in  the  majority 
of  instances  descends  from  the  tube  into  the  uterus. 

Primary  Tuberculosis  of  the  Fundus.— The  only  authenticated 
case  of  primary  tuberculosis  of  the  fundus  is  one  which  Havischka 
considered  he  was  Justified  in  classing  as  such,  as  after  hysterectomy 
no  evidence  of  tuberculosis  elsewhere  could  be  detected,  though  the 
endometrium  and  muscle  were  found  to  be  tuberculous.  Still,  here 
the  mucosa  of  the  tubes  was  also  involved,  and  it  is  possible  that 
this  may  have  been  the  primary  seat  of  the  disease. 

Histology  and  Varieties. — Pozzi  divides  tuberculosis  of  the  uterus 
into  these  forms  :  acute  miliary,  interstitial,  ulcerative. 

The  first,  or  acute  miliary  tubercle,  is  simply  a  sequence  of  the 
general  infection  of  the  entire  sy.stem. 

The  interstitial  is  a  rare  and  essentially  chronic  form,  yet  it  may 
manifest  itself  through  uterine  accidents  and  injuries,  the  results  of 
parturition. 

The  ulcerative  type  is  the  most  frequent  and  the  most  important. 
In  the  early  stage  the  diagnosis  is  most  difiicult,  and  the  affection 
simulates  chronic  endometritis. 

Stolper  regards  these  as  but  different  stages  of  the  same  patho- 
logical conditions,  seeing  that  they  are  often  to  be  found  co-existing 
in  the  same  uterus. 

Paul  Petit  considers  the  follow-ing  as  the  more  characteristic 
histological  appearances  :  A  diffusi(jn  of  dying  or  atrophied  cells  ; 
giant  cells,  in  variable  numbers ;  embryonic  nodules  detached  from 
the  stroma  developed  in  the  vicinity   of  the  vessels,  the  lumen  of 


636  DISEASES   OF   WOMEN. 


which  may  or  may  not  be  preserved ;  numerous  changed  glands 
altered  in  shape,  dilated,  and  with  the  epithelium  lining  them 
elongated  or  in  a  state  of  transformation.  The  possibility  of  some 
morbid  process  in  the  uterus  having  preceded  the  tubercular  infection 
has  to  be  remembered.  A.  Martin  has  recorded  one  such  case  of 
carcinoma  complicating  the  tuberculosis. 

Schmorl,  Lehmann,  Birsch-Hirschf eld,  and  others  have  shown  that 
congenital  tuberculosis  may  be  due  to  passage  of  the  tubercle  bacilli 
through  the  placenta  to  the  organs  of  the  foetus.  The  bacilli  were 
found  in  three  cases  in  the  foetal  placenta.*  In  Anach's  case,t 
where  the  infected  mother  died  three  days  after  labour,  tuber- 
culosis was  present  in  the  placenta,  and  in  the  case  of  her  infant, 
who  survived  for  twenty-six  days,  bacilli  were  found  in  the  liver, 
spleen,  lungs,  and  kidney.  I  have  known  several  instances  of 
exacerbation  of  all  the  symptoms  of  phthisis  during  pregnancy,  and 
a  rapid  fatal  collapse  after  delivery. 

Tuberculosis  of  the  Fallopian  Tubes. 

Frequency. — As  has  been  already  said,  it  is  in  this  intermediate 
link  of  the  genitalia  between  uterus  and  ovary  that  the  diseases  is 
most  frequently  manifested.  Murphy  gives  the  results  of  4586 
necropsies  made  by  Schramm,  von  Winckel,  DonliofF,  Fredrichs,  and 
von  Rosthorn.  In  67  instances  the  tubes  were  tuberculous.  In  814 
cases  of  salpingitis  reported  by  Martin,  von  Rosthorn,  and  Williams, 
the  tubes  were  tuberculous  in  29. 

As  to  age,  Maas  could  find  but  eight  cases  of  tuberculosis  of  the 
tubes  recorded,  including  his  own,  that  of  a  child  aged  five  years. 
The  uterus  here  was  also  involved,  and  the  ovaries  and  vagina  were 
free.  The  infection  appeared  to  have  travelled  from  the  umbilicus 
by  the  parietal  peritoneum.  In  one  of  Kimdral's  cases,  no  other 
focus  being  discoverable,  the  affection  was  regarded  by  him  as  primary ; 
and  in  another,  cancer  of  the  cervix  co-existed  with  the  tuberculous 
disease  in  the  tube, 

'  Why,'  asks  Murphy,  '  does  the  tube  become  involved  while  all 
the  intermediate  portion  of  the  genital  tract,  from  the  vulva  to  the 
fundus,  escapes  1 '  He  ascribes  this  immunity  to  the  greater  resisting 
power  of  these  intervening  structures. 

Varieties. — Miliary,  chronic  diffuse,  and  chronic  fibroid  tubal 
tuberculosis    have    been    described.     Martin    and    von    Rosthorn 

*  Amer.  Surg.  Bull.,  Mar.  15,  1895.  f  Murphy,  he.  cit. 


TUBEKCUfJ.iSIS   or    THE    FEMALE   dEXITALfA. 


G37 


difierentiate  acute  secondary  and  chronic  primary  tuberculosis  of 
the  tubes. 

In  miliary  tuberculosis  miliary  tubercles  are  scattered  over  and  on 
the    tubes,   and  more   especially   at  the  outer  end,   which  may   be 


Fig.  440. — Tubal  Tubekcclosis,  with  One  Tube  hatisg  its  Abdominal 
Ostium  closed  and  the  other  Tube  open.    (Muepht.) 

enlarged.  Leucocytic  infiltrations  and  small  abscesses  are  not 
infrequent,  and  resulting  adhesions  attaching  the  fimbriated  end  of 
the  tube  to  the  surrounding  structure. 

The  conditions  are  well  exemplified  in  the  case  of  Cullingworth's,  in  which 
abdominal  section  was  carried  out  for  pelvic  peritonitis,  the  patient  at  the 
time  suffering  from  tubercle  of  the  apex  of  the  right  lung. 


Fig.  441. — Tubekcle  of  the  Fallopian  Tube,  showing  General  Enlarge- 
ment ov  the  Tube,  both  in  Length  and  Breadth,  with  Irregular 
Dilatations,  corresponding  to  Deep  Ulcers  ox  the  Inner  Surface 
filled  with  Caseating  Tubercle.    (Cullingworth.) 

Miliary  tubercles  are  seen  on  the  peritoneal  surface,  chiefly  near  the  fimbriated 
end.  The  uterine  end  of  the  tube  is  much  twisted.  The  fimbriated  end  is 
nearly  occluded  by  purse-string  contraction. 

'  The  peritoneal  surface  of  the  uterus.  Fallopian  tubes,  and  adjacent  coils 
of  intestine  were  studded  with  miliary  tubercles.      The  uterus  was  pushed 


638 


DISEASES    OF    WOMEN. 


forwards  by  a  mass  behind  it,  consisting  of  a  small  cystic  ovary  with  the 
enlarged  and  thickened  right  tube  curving  round  it,  the  whole  so  densely 
adherent  that  nearly  an  hour  was  occupied  in  the  separation.  The  left  tube 
was  exceedingly  tortuous,  much  thickened,  and  universally  adherent,  the 
adhesions  being  more  recent  than  those  on  the  right  side.  The  left  ovary 
contained  a  large  cyst,  but  was  not  enlarged,  it  was  entirely  surrounded  by 
adhesions,  and  its  external  covering  was  thickened  and  opaque. 


X250 

Fig.  442. — Tubercular  Salpingitis.    (Cdllingworth — Drawing  by 
Mr.  C.  H.  James.) 

a,  transverse  section  of  tube  under  a  power  of  x  50 ;  and  b,  section  through  a 
tubercular  nodule  under  a  power  of  X  250,  showing  two  giant  cells,  a, 
peritoneum ;  h,  tubercular  nodules  in  subperitoneal  tissue ;  c,  longitudinal 
muscular  coat  of  Fallopian  .tube ;  d,  blood-vessels ;  e,  circular  muscular  coat ; 
/,  liypertrophied  mucous  membrane,  showing  numerous  tubercular  nodules 
containing  giant  cells — the  lining  epithelium  still  remains  in  places;  g, 
lumen  of  tube  ;  A,  remains  of  ciliated  epithelium  ;  i,  giant  cells  ;  h,  epithe- 
lioid cells  ;  I,  space  lined  with  columnar  epithelium. 

'  On  examining  the  parts  removed,  the  portion  of  right  tube  was  3  inches 
long  and  l\  broad.  The  walls  were  like  cartilage,  and  measured  -^-  to  J  of  an 
inch  in  thickness.  The  mucous  membrane  was  much  swollen.  The  free  end 
of  the  tube  was  buried  amongst  the  adhesions.  The  portion  of  this  left  tube 
measured,  while  still  unstretched,  2|  inches.  It  was  twisted  at  its  uterine 
end  like  a  corkscrew.     At  the  centre  there  was  a  dilated  portion  f  of  an  inch 


rrin.ncn.osis  aF  riii-:  i-i:mai.k  genitaija.  gio 


long,  softer  than  the  rest  uf  the  tube.     Tlie  iimcous  membrane  was  deej^ly 
ulcerated,  sliowing  dcci>  pits  full  of  caseating  tubercle.' 

In  chronic  diffuse  tuberculosis  the  amount  of  enlargement  and 
distention  of  the  tube  varies,  and  the  sausage-shaped  tumours  are  of 
varying  size,  while  the  fimbriated  ends  of  the  tube  are  closed,  and 
adhesions  frequently  bind  down  the  pyosalpinx  posteriorly  in 
Douglas'  sac. 


Ot" 


n't  1/ 


Ut.Entl 


Fig.  443. — Tubekculau  Left  Tube  with  Adherent  Omentum. 
(Howard  Kelly.) 

(Nat.  size.) 

Fibroid  Variety. — In  the  chronic  fibroid  varieties*  the  walls  of  the 
tubes  are  thickened  by  excessiv^e  development  of  fibrous  tissue  and  the 
fimbriated  end  of  the  tube  is  closed.  It  is  essentially  a  chronic 
afi'ection,  and  does  not  involve  the  same  risks  as  the  other  forms, 
being  in  itself  of  a  conservative  nature. 

Murphy  thus  summarizes  the  pathological  anatomy  of  the  affection  : 
'  The  tubes,  as  a  rule,  are  enlarged,  moderately  firm  in  consistency, 
and  the  serous  covering  is  thickened.  They  may  be  covered  with  a 
false  membrane  in  which  nodules  may  be  noticed .  The  calibre  usual  ly 
enlarges  towards  the  abdominal  end  (cornucopia  shaped) ;  the  fimbrife 
are  swollen,  and  frequently  have  nodular  thickenings.  The  abdominal 
opening  may  be  patent,  partly  closed  with  a  caseous  plug  protruding 
from  it,  or  impermeable.     In  this  latter  event,  a  pyosalpinx  rapidly 

*  Jolms  HopMns  Hospital  Reports,  vol.  iii.  p.  8.t. 


640 


DISEASES   OF   WOMEN. 


forms,  which  may  reach  enormous  proportions  (two  litres,  Stelimana). 
If  the  fimbriated  end  be  open — which  is  often  the  case, — if  its  walls 
be  infiltrated  with  a  non-mixed  infection,  caseous  debris  is  discharged 
into  the  peritoneal  cavity.  As  the  tube  frequently  contracts 
adhesions  to  the  adjoining  viscera,  cavities  may  be  formed  into  which 
these  masses  are  emptied,  or  become  encysted.  Finally,  by  the 
adhesion  of  the  false  membranes  to  the  tube  and  the  viscera,  every- 
thing is  matted  together  into  one  mass.' 

Nodular  Salpingitis  (Tubercular). — That  the  nodular  condition 
of  tube  referred  to  under  this  name  is  not  peculiar  to  any  special 
form  of  salj)ingitis  is  well  known,  as  it  is  found  in  other  chronic 
states  as  well  as  in  the  tubercular  variety.* 

In  many  cases  nodules  are  present  in  the  pouch  of  Douglas,  and 
on  the  broad  ligament  which  can  be  felt  tlirough  the  vagina. 
]\Iurphy  gives  the  details  of  a  case  of  tubercular  salpingitis  in  which 
the  abdomen  was  opened  ten  months  after  the  previous  coeliotomy, 
and  the  peritoneum  was  then  found  to  be  quite  free  of  any  vestige 
of  tuberculosis.  This  salutary  consequence  of  removal  of  the  focus 
of  infection  is  verified  by  similar  results  in  other  cases. 

Effect    on    Menstruation.  —  That    menstruation    may    continue 


Fig.  4i4. — Shows  Tubekcclosis  of  Tubes  with  End.s  closed,  with  Abscess 

OF    OVAET    ON    THE    LeFT    SiDE.       (MtIKPHT.) 


regular,   even  if  both  tubes  be  aifected,  so  long  as  the  uterus  is 
healthy,  is  shown  by  Orthmann  and  AYilliams. 

*  See  cliapter  on  Fallopian  Tubes. 


PLATE    XLVIII. 


[|A^'  e 


Peimaey  Tubeeculosis  of  the  Fallopian  Tube— Pyo-salpixx. 


Same — Sac  opened  eegm  behind. 


[ro/ace_p.  641. 


TUBERCULOSIS  OF  THE  FEMALE   GENITALIA.  641 


Primary  Tubal  Tuberculosis.  —  Abdominal  Coeliotomy  -Sub- 
sequent Curettage,  followed  by  Pregnancy  and  a  Twin 
Labour. 

The  tube  (Plate  XL VIII.)  was  removed  from  a  patient,  aged  22.  She  had 
been  married  for  two  years  and  a  half  at  the  time  of  operation,  and  had 
completed  her  first  pregnancy  at  the  end  of  the  first  year  of  Iier  married  life. 
She  was  brought  to  me  by  Dr.  Disney  in  January,  1901,  and  cumpiained  of 
considerable  and  constant  pain  in  the  left  side,  with  inability  to  walk  and 
dyspareunia.  The  catamcnia  had  been  regular  and  normal.  On  exami- 
nation, the  adnexa  on  the  left  side  were  found  much  enlarged,  softened,  and 
very  sensitive.  The  right  adnexa  were  not  enlarged,  but  adherent.  Imme- 
diate operation  was  advised,  either  exploration  by  colpotomy  or  abdominal 
coeliotomy,  the  afiected  adnexa  to  be  dealt  with  either  by  removal  or  resection, 
according  to  ckcumstances.  This  was  practically  agreed  to,  but  operation 
was  subsequently  declined  by  the  advice  of  a  distinguished  obstetric  phy- 
sician who  saw  her  immediately  after,  and  who  expressed  the  hope  that  by 
rest  and  a  course  at  Woodhall  Spa  she  would  get  quite  well. 

I  did  not  see  the  patient  again  until  the  July  following.  I  operated  on  her 
the  next  day.  Pain  had  then  been  for  some  time  agonizing,  and  she  herself 
demanded  operation.  The  right  Fallopian  tube  was  distended  with  pus, 
forming  a  long  crescentic  swelling  an  inch  and  a  half  in  diameter  at  its 
■widest  part,  the  surface  of  the  tube  being  adherent.  The  right  ovary, 
though  fixed  by  some  adhesions,  was  healthy.  A  large  perimetric  cystoma 
had  formed  behind  the  meso-salpinx,  between  the  distended  tube,  the  ovary, 
and  the  adjacent  viscera.  The  following  is  the  conclusion  of  Mr.  Targett's 
report : — 

'The  external  surface  of  the  specimen  is  covered  with  thin  fibrous  adhe- 
sions in  wbich  many  miliary  tubercles  are  embedded.  The  lumen  of  the 
tube  is  filled  with  thick  caseous  pus,  and  the  inner  surface  is  shaggy  from 
ulceration  of  the  mucous  membrane.  There  is  very  little  thickening  of  the 
wall  of  the  tube  anywhere,  and  in  some  parts  it  is  much  thinned  by  dis- 
tension and  ulceration.  Microscopical  sections  of  the  imdilated  uterine  end 
of  the  tube  exhibit  general  thickening  of  the  mucous  membrane  and  infiltra- 
tion with  miliary  tubercles.  The  epithelial  lining  is  for  the  most  part  intact,' 
There  was  some  endometric  discharge  at  the  end  of  1902.  I  curetted  the 
uterus,  but  there  were  no  evidences  of  tubercle.  The  patient  was  delivered 
in  1903  of  twins,  which  are  now  (1904)  quite  healthy  children,  and  she  again 
has  been  confined  of  a  healthy  child. 

Primary  Tuberculosis  of  Fallopian  Tube  with  Haemato-Salpinx. 

The  macroscopical  and  microscopical  specimens  (Plates  XLIX.  and.L.)]were 
prepared  for  me  by  J.  H.  Targett,  who  has  furnished  me  with  the  pathological 
report.  The  lady  from  whom  the  adnexa  were  removed  first  consulted  me  early 
in  May  of  1899.  She  then  complained  of  pain  in  the  right  side,  pain  after 
passing  water  and  attendant  irritation  of  the  bladder.  Previous  treatment 
had  been  fruitless.     She  was  twenty-nine  years  of  age ;  in  other  respects 


642  DISEASES   OF   WOMEN. 

she  had  very  good  health,  and  was  of  a  healthful  appearance.  The  constant 
pain  interfered  with  her  happiness,  and  kept  her  more  or  less  an  invalid. 
Her  catamenia  were  regular.  The  uterus,  on  examination,  was  found  to  be 
small ;  there  was  a  tumour  of  the  right  adnexa,  the  left  were  normal.  At 
the  time  palliative  treatment  was  resolved  upon,  and  she  returned  home.  In 
June,  being  no  better,  and  the  pain  still  continuing,  as  also  the  bladder 
symptoms,  salpingo-oophorectomy  was  performed.  She  made  an  excellent 
recovery,  and  the  bladder  symptoms  disappeared. 

Report  on  Tuberculous  Fallopian  Tube. 

'  The  outer  half  of  the  tube  is  considerably  enlarged,  and  its  lumen 
uniformly  dOated.  The  abdominal  ostium  is  closed  by  adhesions,  but  traces 
of  the  fimbriae  can  be  discerned  on  the  exterior'.  The  surface  of  the  tube  is 
generally  free  from  adhesions,  though  there  are  a  few  fibrous  threads  on  the 
ovary.  A  section  across  the  dilated  portion  of  the  tube  shows  a  marked 
thickening  and  rugosity  of  the  mucous  coat,  as  well  as  a  finely  granular 
appearance  of  the  mucous  surface.  The  lumen  is  filled  with  blood  and 
retained  secretion.  Microscopical  examination  reveals  an  abundance  of  grey 
tubercles  in  the  substance  of  the  mucous  membrane,  the  giant  cell  systems 
being  well  developed.  The  muscular  coat  is  not  yet  invaded,  though  the 
tuberculous  formation  has  advanced  in  that  direction.  The  epithelial  cover- 
ing of  the  thickened  rugae  is  for  the  most  part  preserved.  The  adjacent 
ovary  presents  a  recent  corpus  luteum,  and  its  substance  is  healthy.  There 
is  a  striking  absence  of  any  peritoneal  lesion,  and  for  this  reason  it  is  pro- 
bable that  the  tuberculosis  of  the  Fallopian  tube  is  primary.'  I  saw  this 
patient  recently ;  she  was  then  in  perfect  health. 

Shober  has  reported  a  case  of  ectopic  gestation  associated  with 
tuberculosis  of  the  tubes. 

Tuberculosis  of  the  Ovary. 

Murphy  groups  394  cases  of  genital  tuberculosis  reported  by 
Speath,  Merletti,  and  Orthmann.-  Of  these,  76  had  the  ovary 
implicated.  Of  57  cases  of  absolute  diagnosis  by  microscopic 
examination,  collected  by  Orthmann,  9  were  tubercular  ovarian 
cysts,  and  48  were  tubercular  ovaries.  Terrillon,  in  1889,  first 
recorded  3  undoubted  cases  of  tubercle  of  the  ovary. '•  Primary 
tubercular  disease  of  the  ovary  is  so  rare,  and  the  evidence  so 
doubtful  as  to  its  occurrence,  that  for  practical  purposes  it  need  not 
be  taken  into  account.  In  Max  Madeleuer's  case  the  opposite 
Fallopian  tube  contained  caseous  material,  and  there  was  an  abscess 
on  the  posterior  wall  of  the  uterus,  the  patient  dying  of  phthisis.f 

*  Arch,  de  Tokol.,  Aug.,  p.  581.  f  Central,  f.  Gyn.,  June,  1894. 


PLATE    XLIX. 


AUNEXA,    SHiiWIXG    SeCTIOX    CiF    THE    DiLATED    TcBE    AXD    THE    C'OXTAIXED 

Blood  Coagulem  ;  also  the  Ahhekext  Fijibiua.     (Author.) 
Tuberculosis  of  the  P'aUopian  Tube  (seen  from  above  and  in  front). 


SAaiE  Specluex,  .?H0's^^^"G  the  Otakt  cet  open  axb  the  kecext  Corpes 
LrTETTM.    (Aethor.) 

Tuberculosis  of  the  Fallopian  Tube  (seen  from  behind). 

[To  face  p.  642. 


PLATE   L. 


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^ ' .    n 


.,/, 


z'-^,-. 


PkIMAEY    Tl'BEECULOSIS    of    -tALLOriAX    TlBE.        X    lUU.       (AliTHOE.) 

flection  from  tube,  Plate  XLIX. 
PL/VTE    LI. 


r<^    ^r       ___      Q^- 


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Acute  Tubeeculosis  of  Fallopian  TtjBe.     x  oU.    (J.  stevensos.; 

From  a  case  operated  upon  in  Landau's  Klinik.    \To  face'p.  643. 


TUBERCULOSIS   OF   THE    FEMALE   GENrJMJ. 


(m: 


As  a  rule,  the  ovaries  are  infected  either  through  tlie  tubes  or 
peritoneum,  the  latter  being  the  more  frequent  source  of  invasion. 
The  periodic  rupture  of  the  Graafian  follicles,  Schottlander  considers, 


■%;.? 


:^^ 


Fig.  44.5. — Tuberculosis  of  the  Tube,    (Kelly.) 
Posterior  surface  of  the  left  ovary  and  tube.     (Natural  size.)     The  meso- 
salpinx has  disappeared,  so  have  the  fimbrise. 


invites    the   infection   through  the  consequent  traumatism.      The 

tubercular    deposit    may   be 

found  on  the  peritoneum,  in 

the  stroma,  or  in  the  Graafian 

follicles,  and  be  of  the  miliary  • 

or  caseous  suppurative  forms. 

If  the  tuberculosis  infect  the 

peritoneum  and  tunica  albu- 

ginia,  it  may  not    penetrate 

the  ovarian  stroma. 

Primary  Tuberculosis  of 
Ovary. — Gemmel  brought  be- 
fore the  North  of  England 
Obstetrical  Society  a  case  of  primary  tuberculosis  of  both  ovaries, 
in  a  patient  aged  26.  The  fimbriated  end  of  one  tube  was  involved 
where  it  was  adherent  to  the  ovary.  There  was  no  evidence  of  any 
tubercle  in  any  other  organ  of  the  body. 


Fig.  446.— Tubekgular  Tubo-(jvai;iax 
Abscess.     (Murphy.) 


644  DISEASES   OF   W02IEX. 


Treatment  of  Genital  Tuberculosis  generally. 

Vulva. — The  -syhole  affected  area  should  be  excised,  and  the 
actual  cautery  (Paquelin's)  applied.  If  it  be  feasible,  the  margins 
of  the  skin  can  be  brought  together  with  bronze  aluminium  sutures, 
or,  as  is  preferable,  by  a  transplantation  operation.  Otherwise  a 
Tiersch's  grafting  can  be  made.  Or,  the  tubercular  tissue  having 
been  excised,  the  chloride  of  zinc  paste  may  be  spread  on  a  piece  of 
linen,  placed  neai'  the  exposed  surface.  This  latter  is  subsequently 
dealt  with.  The  X-ray  or  radium  treatment  may  be  tried  should 
the  disease  recur. 

Vagina. — As  the  disease  generally  affects  the  upper  portion  of 
the  canal  and  either  fornix,  while  the  portio  is  also  diseased,  the 
treatment  must  consist  of  amputation  of  the  cervix  and  the  affected 
portion  of  the  vaginal  wall.  If  the  disease  have  seriously  involved 
the  uterus,  or  have  travelled  from  the  tubes  down,  then  hysterec- 
tomy is  indicated.  Should  the  disease  be  diagnosed  in  its  very  early 
stages,  and  be  limited  to  the  cervix  and  vault  of  the  vagina,  the 
actual  cautery  or  the  chloride  of  zinc  treatment  may  suffice  to  arrest 
it.  If  the  cervix  be  slightly  infected,  curettage  and  the  application 
of  chromic  acid  (^i.-Ji.)  should  be  tried  at  the  same  time. 

Cervix  and  Fundus. — However  unsatisfactory  the  results  may  be 
of  any  operative  treatment  in  tuberculosis  of  the  uterus,  still  the 
only  course  open  is  that  of  the  radical  step  of  pan-hysterectomy. 
As  has  been  just  said,  should  the  disease  be  localized  in  the  cervix, 
free  curettage  with  the  application  of  chromic  acid,  or  high  amputa- 
tion of  the  cervix  with  ligature  of  the  uterine  arteries,  may  be  tried. 
The  chloride  of  zinc  treatment  applied  as  in  carcinoma  is  here  also 
suitable.  Atmocausis  or  zestocausis  might  have  a  good  effect. 
When  the  disease  is  in  the  fundus,  there  is  little  option,  and  the 
patient  should  be  given  the  chance  of  a  pan-hysterectomy. 

Fallopian  Tubes. — -Removal  of  the  affected  tubes  is  the  sole 
treatment  for  tubercular  salpingitis.  The  question  of  removal  of 
ovary  or  uterus  at  the  same  time  is  dependent  upon  the  presence  of 
the  affection  in  either  or  both  of  these  organs.  Unless  the  ovaries 
be  .quite  free  of  the  disease  they  should  be  removed,  and  the  same 
course  must  be  followed  with  regard  to  the  uterus. 

Ovary. — If  the  tubercular  disease  be  located  in  one  portion  of  the 
ovary,  and  not  diffused  throughout  its  substance,  the  stroma  and 
the  follicles  being  healthy,  while  tuljercles  are  not  scattered   over 


TUBERCULOf^IS   OF   THE   FEMALE   GE2s ITALIA.  nif) 


its  surface,   the   ovnry   should    tlien   be    resected   and    the   healthy 
portion  preserved. 

The  Effect  of  Laparotomy  in  Tuberculosis  of  the  Female  Genitalia  and  the 
Peritoneum. — The  number  of  cases  which  liave  been  reported  as  relieved, 
and  in  several  instances  cured,  by  the  operation  of  coeliotoray  when  there  has 
been  tuberculosis  of  the  peritoneum  alone  or  of  the  internal  genitalia,  has 
proved  clearly  the  beneficial  effects  which  follow  the  opening  of  the  peritoneal 
cavity  in  these  cases.  Sippel,  of  Frankfort,  accounts  for  the  favourable 
result  by  the  formation  of  a  curative  serum  following  the  hyperjemia,  the 
result  of  the  operation.  Baumgart  regards  vaginal  coeliotomy  as  curative  as 
the  abdominal.  He  advocates  a  short  abdominal  incision.  Like  Carpenter, 
he  insists  on  the  importance  of  rectal  examination  in  diagnosis.* 

Ligature  of  the  Ovarian  Arteries  in  Tuberculosis  of  the  Adnexa. — In 
certain  cases  of  inoperable  malignant  disease,  as  in  myoma,  ligature  of  the 
ovarian  or  utero-ovarian  vessels  has  been  followed  by  amelioration  of  the 
symptoms  and  arrest  of  the  disease.  Lindfors,  of  Upasala,  has  reported  a 
case  of  inoperable  tuberculous  disease  of  both  adnexa,  in  which  there  were 
extensive  adhesions  of  the  tubes,  to  the  ovaries  and  pelvic  peritoneum.  In 
this  case,  however,  the  presence  of  tuberculous  affection  was  only  surmised, 
as  no  proper  histological  examination  was  made.f 

Abdominal  or  Vag-inal  Routes. 

Various  operators  prefer  the  vaginal,  while  others  resort  to  the 
abdominal  route  in  the  extirpation  of  the  tuberculous  genitalia. 
In  the  rare  cases  in  which,  though  the  adnexa  are  affected  as  well 
as  the  uterus,  the  former  are  not  adherent,  Faure  recommends 
vaginal  hysterectomy  with  bisection  of  the  anterior  wall  after 
Doyen's  method,  and  with  the  removal  of  the  adnexa.  In  the  more 
common  cases,  recourse  must  be  had  to  laparotomy  and  a  much 
wider  removal  of  the  adnexa  than  need  be  undertaken  in  forms  of 
disease  in  which  conservative  ideas  may  be  entertained.  An  excep- 
tion may  be  made  when  the  disease  is  confined  to  one  side,  but 
when  both  are  afiected,  the  uterus  should  also  be  removed.  In  any 
case,  when  the  adhesions  are  organized  and  firm,  the  removal  of  the 
uterus  greatly  facilitates  that  of  the  adnexa.  Should  acute  or  sub- 
acute inflammation  complicate  the  case,  or  if  there  be  active  and 
disquieting  symptoms  due  to  suppuration  from  secondary  infection, 
the  vaginal  operation  is  to  be  preferred ;  but  such  complications 
are  not  common,  as  genital  tuberculosis  is  generally  slow  in  its 
course. 

Should    there    be    no    adhesions,   the   technique    of    the   vaginal 

*  Deutsche  Med.  Wclms.,  1901,  Xos.  2,  3. 
t  Centra]}),  f.  Chjn.,  1900,  Xo.  41. 


646  DISEASES   OF   WOMEN. 

operation  is  the  same  as  in  ordinary  cases;  if  such  be  present 
they  should  be  detached  piece  by  piece.  When  the  uterus  must 
be  removed,  it  is  better  to  work  from  below  upwards  by  a  sub- 
total hysterectomy,  followed  by  the  removal  of  the  adnexa,  in  doing 
which  the  greatest  care  should  be  taken  not  to  injure  the  attached 
viscera.  If  the  case  be  an  easy  one,  the  operation  may  be  performed, 
as  usual,  from  above  downwards ;  and  in  the  most  simple  cases  he 
recommends  the  method  he  uses  for  myomata,  that  is,  section  of  the 
isthmus  of  the  neck  from  behind  with  scissors,  traction  on  the 
cervix,  and  the  division  of  the  broad  ligament  on  one  side  after 
the  application  of  a  forceps  to  the  outer  side.  When  the  disease  is 
unilateral,  Faure  recommends  Kelly's  method  of  dividing  the  broad 
ligament  on  the  unaffected  side  ;  then  cutting  through  the  neck  with 
scissors  and  dividing  the  ligament  of  the  affected  side  from  below 
upwards,  securing  the  arteries  either  before  or  after  the  section. 

Pozzi  also  advises  the  abdominal  route  with  pan-hysterectomy. 
As  between  the  two  routes,  there  can  be  no  doubt  that  the 
abdominal  offers  the  largest  scope  for  complete  extirpation  of  all  the 
affected  parts,  and  less  chance  of  secondary  contamination.  There- 
fore, in  cases  in  which  the  disease  has  attacked  the  internal 
genitalia,  and  where  the  evidence  leans  to  the  side  of  their  serious 
involvement,  abdominal  cceliotomy  is  the  safer  route  to  follow.  On 
the  other  hand,  when  the  disease  is  more  localized,  in  the  cervix,  or 
to  the  fundus,  and  the  adnexa  appear  to  be  free  and  movable,  the 
vaginal  route,  exposing  less  of  the  peritoneum,  and  involving  less 
risk,  is  preferable. 

I  am  indebted  to  F.  Edge  for  the  following  abstract  of  the  '  very  extended 
and  laborious  investigation  of  the  anatomical  and  clinical  aspects  of  tubercu- 
losis of  the  female  genitalia '  by  Merletti  *  : — 

Tuberculosis  of  the  genitals  is  met  with  in  12'6  per  cent,  of  tubercular 
women,  but  in  only  2*4  per  cent,  of  tubercular  men.  In  tubercular  women 
genital  tuberculosis  is  met  with  in  22-8  per  cent,  during  the  childbearing  age, 
in  7-3  per  cent,  before  puberty,  and  in  20'6  per  cent,  after  the  menopause. 
In  18-6  per  cent,  genital  tuberculosis  is  primary. 

Tuberculosis  of  the  uterus  was  met  with  in  75  out  of  172  cases  in  which 
the  genitals  were  affected.  In  the  great  majority  of  instances  the  infection  of 
the  uterus  was  secondary  to  that  of  the  tubes. 

Hyperplasia  of  the  genitals  may  be  accepted  as  an  anatomical  condition 
favouring  the  development  of  tubercle. 

Cervical  tuberculosis  is  met  with  in  three  forms :  (a)  the  miliary,  which .  is 
the  most  easily  recognized ;  (J)  the  catarrhal,  which  may  be  mistaken  for 

*  Archivio  di  Ostet.  e.  Ginec,  1901. 


rrnERCiTOsrs  of  the  female  (ienita/./a.  cii 


sirriple  catarrlial  cervicitis ;  and  (c)  the  ulcerous  form,  which  macro-  and 
microscopically  may  very  closely  resemble  cancroid  of  the  vaginal  cervix. 

Petit's  distinction  of  the  forms  which  tubercle  may  assume  in  the  body  of 
the  utonis,  as  '  endometritic,'  *  interstitial,'  i^nd  '  mixed,'  is  the  most  expedient 
from  the  clinical  and  the  most  exact  from  the  anatomical  point  of  view. 

The  microscopical  demonstration  of  bacilli  in  the  uterine  secretion  in  cases 
of  tubercular  disease  of  the  uterus  itself,  or  of  the  adnexa,  is  extremely  difficult. 
When  the  endometrium  is  the  seat  of  the  disease,  curettage  may  aid  in  the 
diagnosis  by  permitting  the  recognition  of  characteristic  lesions  (giant  cells, 
tubercular  follicles),  but  except  in  the  earlier  stages  of  the  disease,  the  bacilli 
are  as  hard  to  find  in  the  scrapings  of  the  uterus  as  in  the  secretion. 

The  inoculation  of  animals  with  the  uterine  secretion  is  most  valuable  in 
the  semeiology  of  tuberculosis  of  the  uterus  or  of  the  appendages. 

There  is  some  reason  to  believe  that  the  uterine  secretion  may  be  infectious 
when  the  tuberculosis  affects  the  peritoneum  only,  and  not  the  uterus  or 
adnexa. 

The  tities  are  the  most  favourable  seat  for  the  disease,  and  were  affected 
in  157  out  of  the  172  cases  of  genital  tuberculosis ;  tubal  tuberculosis  is 
generally  bilateral. 

In  tubercular  salpingitis,  more  often  than  in  other  kinds  of  inflammation, 
owing  to  the  constant  closure  of  the  abdominal  ostia,  and  the  hyperplasia 
generally  affecting  the  tubes  (W.  A.  Freund),  an  objective  sign  for  diagnosis 
may  be  found  in  the  presence  of  a  tumour  in  form  like  a  rosebud. 

The  following  forms  of  tubercular  disease  of  the  tubes  have  been  recognized  ; 
(a)  A  tubercular  perisalpingitis,  in  which  the  serosa  only  is  the  seat  of  granu- 
lations ;  (6)  a  miliary  parenchymatous  salpingitis,  in  which  the  mucosa  and 
musculosa  are  both  affected  ;  a  tubercular  endo-salpingitis,  in  which  the 
mucosa  alone  is  involved  (rare,  Williams). 

The  epithelium  of  the  tubal  mucosa  suffers  with  the  evolution  of  the 
disease  ;  the  usual  ending  is  caseous  degeneration. 

The  presence  of  nodules  at  the  isthmus  of  the  tubes  (salpingitis  isthmica 
nodosa)  is  not  pathognomonic  of  tubercle ;  but  such  nodules  are  more  fre- 
quently found  in  this  connection. 

Such  nodules  are  either  congenital,  to  be  referred  to  >[iiller's  or  Wolff's 
ducts,  or  are  due  to  some  chronic  inflammatory  process  (gonorrhcea,  tubercle, 
etc.). 

The  ovary  exhibits  a  certain  resistance  to  tubercular  infection  (only  25 
instances  in  172  cases  of  genital  tuberculosis).  This  seems  most  probably  to 
arise  from  the  timely  beneficial  protective  action  of  exudations  and  adhesions 
of  the  pelvic  peritoneum  by  which  the  gland  has  been  encapsuled ;  peri- 
oophoritis is  common,  but  true  oophoritis  is  rare. 

More  than  half  of  the  tubercular  ovaries  met  with  exhibit  cystic  degeneration. 

The  tubercular  process  seems  to  originate  in  the  elements  of  the  stroma, 
and  not  in  those  of  the  ovisacs. 

In  diagnosis,  gi'eat  value  is  to  be  given  to  the  prominence,  on  digito-rectal 
examination,  of  granules  and  nodules  about  Douglas'  pouch  and  the  sacro- 
uterine ligaments  (granulo-nodular  Douglasitis),  also  the  general  condition  of 
the  patient,  especially  as  regards  the  peritoneum,  intestine,  and  lungs. 


CHAPTER  XXXV. 

AFFECTIONS  OF  THE  FALLOPIAN  TUBES. 

Congenital  abnormalities. 
Accessory  tubal  cysts. 

Catarrhal. 

Interstitial. 
Salpingitis  (acute  and  chronic)      Suppurative. 

Tubercular. 

Gonorrhoeal. 
Stricture. 
Hydrops  Tubfe  Profluens. 

Hydro-salpinx       \ 

-o-        i.       1   •  These  three  affections  are  dealt  with  as  the 

Hsemato-salpinx    ) 

-r,         1   •  consequences  of  salpingitis. 

Pyo-salpmx  j  ^  r    o 

Adhesions  and  displacements. 

Carcinoma. 

Papilloma. 

Sarcoma. 

Tubal  pregnancy. 

Dermoid  tumour. 

Calculus. 

Marro  *  found  in  the  Fallopian  tube^  surrounded  by  granular  fatty  matter 
and  crystals  of  cbolestrine,  a  number  of  eggs  of  the  oxyuris  vermicularis.  The 
cyst  was  a  new  growth  in  the  tube. 

An  echinococcus  cyst  in  the  retrocervical  tissue  was  removed  by  Knauer.f 
The  tumour  was  diagnosed  as  uterine,  and  its  true  nature  was  only  discovered 
on  operation. 

I  cannot  discuss  at  length  certain  questions  connected  with 
abnormal  states  of  the  Fallopian  tubes,  which  have  rather  a  patho- 
logical than  a  clinical  interest  attached  to  them.  The  names  of 
Battey,  Lawson  Tait,  Schrceder,  and  Polk  are  linked  with  many  of 

*  Arch,  per  le  Scienze  Med.,  t.  xxx.,  2. 
t  Centralb.f.  Gyn.,  Nov.  23,  1902. 


PLATE   LI  I. 


Sectiox  of  the  Tube.     (ArxHOR.) 

ilagiiification  8  times.  Mucosa  replaced  by  granulations — only  a  few  columnar 
tubes  left  to  represent  plica.  There  is  a  round-celled  infiltration  under 
the  peritoneum,  surrounded  by  a  fibrous  capside ;  infiltration  of  the  musculo- 
tibrous  -wall,  its  vessels  having  hypertrophied  walls.  IToface  p.  <MS. 


PLATE    LIII. 


Chr(jxic  Hypertrophic  Salpingitis. 
Section  of  tlie  left  tube  (Plate  LII.),  showing  parenchymatous  degeneration  and 
general   fibrosis   blocking  and   almost   obliterating   the   lumen.     This   is   the 

secondary  or  atresic  stage. 

,  [To  face  p.  6i9. 


AFFECTIONS   OF   THE   FALLOPIAN   TUBES. 


049 


our  modern  views  of  the  consequences  of  Fallopian  disease,  and  the 
causes  of  the  suflfering  attendant  upon  morbid  states  of  the  tubes 
and  associated  ovarian  diseases,  and  the  later  operative  and  con- 
servative measures  which  are  taken  to  preserve  them  entirely  or  in 
part.  It  will  be  widely  acknowledged  that  Tait  first  established 
the  important  part  played  by  the  Fallopian  tubes  in  perpetuating 
those  chronic  pelvic  troubles  which  removal  of  the  ovaries  alone 
could  not  relieve. 


Structure  of  Walls  of  Fallopian  Tubes. 

jMar\-  Dixon  Jones  describes  tlie  structure  of  the  tubal  walls  as  consist- 
ing of — 

(a)  Six  layers  of  smooth  muscles,  the  principal  two  of  which,  interlaced, 
are  circular  and  longitudinal,  the  latter  being  external. 


Fig.  447.— Chronic  Parexchymatocs  Htperteophic  Salpingitis. 
(x  3.5  diameters.) 

A,  false  membranes;  b,  b,  line  of  surgical  section,  corresponding  to  the  middle 
of  the  broad  ligament;  c,  fibrous  bed  strewn  with  muscular  fasciculi;  d, 
thickened  bed  of  soft  fibres,  mostly  circular ;  e,  mucous  membrane ;  g.  g, 
pseudo-glands  of  cylindrical  epithelium,  due  to  the  welding  together  of  the 
villous  structure;  ml,  longitudinal  fibres. 


650 


DISEASES   OF   WOMEN. 


(h)  Myxomatous  connective  tissue  constitutes  the  inner  surface  of  the  tubal 
wall,  and  here  also  we  find  an  interlacing  longitudinal  and  circular  muscle 
layer.  The  folds  in  the  muscosa  are  produced  by  contractions  and  elongations 
of  these  latter  muscle  layers,  serving  to  occlude  the  tube  during  life. 

(c)  A  plexus  of  blood-vessels,  arterial  and  venous,  is  found  outside  the 
longitudinal  layer  of  the  wall. 

(d)  There  are  also  two  narrow  layers  of  oblique  smooth  muscle  fibres, 
traceable  from  the  uterine  ostium  to  the  fimbriated  extremity,  corresponding 
to  the  two  oblique  layers  of  the  uterine  parietes.  These  layers  regulate  the 
blood-current  in  the  subjacent  arteries  and  veins. 

Bland-Sutton  thus  refers  to  the  changes  produced  by  salpingitis  : — 
'  When  a  healthy  Fallopian  tube  is  examined  in  transverse  section  by  means 
of  a  microscope,  we  distinguish  easily  the  serous  and  muscular  coats  of  the 
tube,  and,  standing  upon  these,  the  so-called  plicae  formed  by  the  mucous  coat. 


-! — .  Submucous  layer. 

I 

.  Ciliated  epithelium. 

Circular  muscular  iibres. 


,.  .  Longitudinal  fibres. 


Fig.  448. — Normal  Fallopian  Tube  in  Section,    (x  10  diameters.) 
(Macalister.) 

Each  plica  consists  of  a  delicate  framework  of  connective  tissue,  fringed  with 
columnar  ciliated  epithelium  on  the  free  surface.  Delicate  strands  of  unstriated 
muscle-cells  may  be  distinguished  near  the  base  of  the  epithelium,  and  in  the 
middle  of  the  fold  are  many  capillaries.  As  a  rule,  a  few  leucocytes  may  be 
seen  scattered  among  the  meshes  of  the  connective  tissue.  When  sections  are 
prepared  from  tubes  which  have  been  for  some  months  past  the  seat  of 
salpingitis,  the  appearances  are  very  different.  The  plicse  are  swollen  to  twice 
or  thrice  the  usual  size,  and  all  the  details  of  their  structure  obscured  by  an 
innumerable  host  of  cells  of  various  sizes.  In  many  places  the  limiting 
epithelium  is  lost,  in  others  it  can  be  detected,  disturbed  and  disarranged, 
here  and  there  seemingly  held  in  position  by  some  glutinous  material.  In 
mild  cases  this  peculiar  cell-infiltration  is  limited,  and  does  not  involve  the 
whole  plica,  but  in  very  diseased  specimens  the  cells  are  not  limited  to  the 
plicse,  but  involve  the  muscular  coat,  and. extend  into  the  connective  tissue 
of  the  mesosalpinx.' 


AFFECTIONS   OF   THE    F ALU)  PI  AX   TUBES.  651 


Salpingitis. 

Diagnosis. — Salpingitis  is  a  much  more  common  affection  than  is 
generally  thought,  especially  during  the  childbearing  period  of  a 
woman's  life.  To  detect  a  swollen  or  thickened  Fallopian  tube,  we 
examine  tlie  patient  by  the  bimanual  method.  We  can  most  fre- 
quently trace  it  from  the  lateral  margin  of  the  uterus  outwards,  and 
feel  its  more  prominent  portion  behind  the  uterus  and  towards 
Douglas"  pouch. 

By  a  careful  examination  we  may  detect  effusions,  thickening, 
enlargement,  adhesions,  or  a  tumour.  Such  diagnosis  requires  ex- 
perience. Taits  view,  as  strongly  urged  by  him,  is  true,  that  in  a 
great  number  of  cases  no  step  save  an  exploratory  abdominal  section 
enables  the  surgeon  to  discover  the  nature  of  the  disease. 


Exploratory  Cceliotomy  in  Suspected  Disease  of  the  Adnexa. 

In  making  an  exploratory  incision,  every  antiseptic  and  aseptic  precaution 
is  taken  before,  during,  and  after  the  operation.  The  incision  into  the 
peritoneal  cavity  should  be  sufficient  to  admit  two  fingers.  Should  further 
enlargement  of  the  wound  be  required,  a  finger  is  carried  in  to  protect  the 
bowel,  and  the  scissors  or  bistoury  is  used  on  this,  cutting  upwards.  Xo  hand 
save  a  perfectly  sterilized  one  should  go  near  or  pass  into  the  wound.  Search 
can  now  be  made  at  either  side,  and  the  adnexa  traced  outwards  from  the 
uterus  and  felt.  Any  tumour  or  enlargement  of  uterus,  tube,  or  ovary  is 
quickly  discovered.  For  further  exploration  of  the  bowel,  spleen,  or  kidneys. 
a  larger  and  differently  placed  incision  will  be  required. 

Owing  to  adhesions,  a  diseased  Fallopian  tube  may  be  carried  in 
front  of,  or  over,  the  fundus  uteri.  Fixation  of  the  pelvic  contents, 
and  the  presence  of  the  characteristic  sausage-like  mass  at  the  side 
of  the  uterus,  are  the  prominent  physical  signs.  Inflammation  and 
disease  may  cause  closure  of  the  uterine  or  fimbriated  end,  more 
frequently  of  the  latter.  On  the  other  hand,  the  inflammatory 
changes  may  lead  to  a  permanently  enlarged  and  open  state  of 
either  orifice.  Such  variations  in  the  size  of  the  orifices,  and  their 
relative  degrees  of  patency,  will  depend  on  the  nature  of  the  in- 
flammatory process  and  the  character  of  the  inter-tubal  secretion. 
In  simple  catarrhal  affections  this  patent  state  of  the  uterine  orifice 
often  appears  to  be  of  an  intermittent  nature.  The  serous  contents 
of  the  tube  may  then  empty  themselves  at  intervals  into  the  uterus 
assisted  by  the  muscular  contraction  of  the  tubal  wall. 


S52 


DISEASES   OF   WOMEN. 


Kelly  finds  three  kinds  of  adhesions  affecting  the  tubo-ovarian  fimbriae,  {a) 
Simple  shortening  due  to  adhesions,  resti'icting  the  area  to  the  tube,  to  which 
the  tube  may  apply  itself  to  a  short  radius  about  the  outer  pole,  (b)  The 
tube  is  contracted  down  to  the  ovary  by  an  obliteration  of  the  outer  portion 
of  the  mesosalpinx,  so  that  it  lies  with  its  orifice  directed  away  from  the 
ovary,  (c)  The  tube  is  flexed  about  the  ovary  with  its  lumen  still  open,  and 
turned  towards  one  small  area  to  which  it  may  be  closely  applied. 

Classification. — Petit  thus   divides   the  various    forms   of    (non-specific) 
salpingitis,  by  their  anatomical  and  clinical  differences  :  * — 

J  Of  mucous  origin. 


Acute 


Non-cystic  salpingitis 


Chronic 


Of  lymphangitic  origin  (very  rare). 
Mucous  or  catan-hal  endosalpingitis. 
Parenchymatous 

I 

Hypertrophic 
and 


Atrophic. 


IHremato-salpinx 
Hydro-salpinx. 
Pyo-salpinx. 

Pozzi  prefers  the  following  classification  :- 

[    Catarrhal 
Acute  non-cystic  salpingitis 
Chronic  non-cystic  salpingitis 


Purulent. 
Parenchymatous  \ 


Cystic  salpingitis 


Hypertrophic. 

Atrophic. 
Hydro-salpinx — serous. 
Hasmato  -salpinx — sanguineou  s. 
Py  o-salpinx — purulent. 


Hydrops  Tubae  Profluens  (Intermittent  Ovarian  Hydrorrhoea).  This  is  a 
comparatively  rare  affection,  and  is  characterized  by  discharges  of  watery  fluid, 
sometimes  tinged  with  blood  from  the  uterus.  It  occurs  at  varying  periods 
before  the  catamenia,  recurring  at  intervals.  Associated  with  this  Fallopian 
discharge,  there  is  obstruction  of  the  abdominal  ostium,  and  also  occasional 
closure  of  the  uterine  end  of  the  tube.  Ingraham  reported  two  such  cases,! 
advocating  this  view,  or  that  there  may  be  temporary  kinking  of  the  tube. 

A.  Martin  describes  but  two  distinct  forms  of  salpingitis :  (1)  Interstitial 
endo-salpingitis ;  (2)  follicular  endo-salpingitis.  There  is  a  degeneration  and 
destruction  of  the  epithelium  and  muscular  elements;  the  lumen  of  the 
tube  becomes  occluded  in  one  part  and  extended  in  another ;  and,  finally, 
suppuration  takes  place. 

Etiology. — There  can  be  no  doubt  that  we  must  look  to  the 
uterus  for  the  source  of  the  great  majority  of  inflammations  of  the 
tubes  and  ovaries.     The  infection  may  travel  through  the  lynaphatics 

*  '  Traite  Pratique  de  Gynsecologie,'  p.  221,  par  Steplian  Bcmnet  et  Paul  Petit. 
t  Amer.  Gyn.,  Feb.,  1903. 


PLATE    I. IV. 


PLATE   LV. 


Traxsverse  Section  of  Fallopi.'Oc  Tubes  exempltftixg  Htpeetkophic  and 
Desquamative  Salpingitis.    (See  Plates  LA'I.  and  LVII.) 
Plate  LIT. — Left  tube.     A  portion  of  the  ovary  (o)  is  included  in  tbe  section :  the 
plicas  are  swollen,  and  there  is  general  desquamation  of  the  cubical  epithelium, 
with  laartial  obliteration  of  the  lumen  of  the  tube.     « — a  limit  of  ovary. 
Plate  LV. — Plight  tube  is  also  the  seat  of  desquamative  salpingitis.     It  is  folded 
on  itself,   and   dissection   is  made   through  the   loop.     The   plicaj   here   are 
cedematous,  and  the  lumen  of  the  tube  is  encroached  upon. 

[To  face  p.  652. 


AFFECnOXS   OF   THE   FALLOPIAN   TUBES.  653 


or  the  blood-vessels.  It  probably  more  often  finds  its  way  by  direct 
oontiuuity  through  the  mucous  membrane.  Endometritis,  whether 
of  a  catarrhal  or  specific  (gonorrhceal)  nature,  is  frequently  the  cause. 
Out  of  987  autopsies  recorded  l)y  Galabiu,  Lemicre,  and  Winckel, 
in  211  there  was  found  some  affection  of  the  adnexa.  The  inflam- 
mation may  doubtless  travel  from  the  tube  to  the  uterus,  but  the 
reverse  is  generally  the  case.  Salpingitis  frequently  accompanies 
uterine  inflammation,  acute  and  chronic,  and  also  peritoneal  and 
pelvic  cellular  inflammations,  and  the  ovary  generally  participates. 
Hence  it  is  commonly  a  consequence  of  the  exciting  causes  which 
predispose  to  these  affections.  It  may  also  attend  on  a  zymotic 
disease. 

I  have  already  referred  to  the  occasional  passage  of  the  uterine  sound  into 
the  tube  in  dilated  or  saccular  states,  and  this  has  an  important  bearing  on 
intra-uterine  medication,  and  the  bad  results  which  may  attend  on  it.  Also,  if 
the  sound  be  not  sterilized,  or  be  passed  into  the  uterus  without  previous  clean- 
ing and  disinfection,  it  may  directly  infect  the  tube  and  cause  pyo-salpinx. 
Stricture  of  the  tube  is  a  well-understood  cause  of  sterility;  it  or  closure 
may  produce  distension  and  accumulation  of  such  fluids  as  mucus,  pus,  or 
blood. 

Distension  may  lead  to  retro-flow  of  the  fluid  or  rupture  of  the 
tube.  Adhesions,  displacements,  cystic  enlargements,  are  also  some 
of  the  remote  results  of  inflammation,  either  primary  or  secondary, 
of  the  tubes.  An  unusually  large  accumulation  of  fluid  is  termed 
tubal  dropsy.  The  possibility  of  hsemato-salpinx  arising  at  any  time 
during  the  growth  of  the  ovum  in  tubal  pregnancy  must  not  be  lost 
sight  of. 

Alban  Doran  *  has  entered  fully  into  the  effects  of  closure  of  the  ostium  of 
the  Fallopian  tube  by  perimetritis  or  salpingitis.  He  showed  that'  in  adhesive 
perimetritis  the  nmbrite  of  the  tube  are  bound  down  by  bands,  which  thus 
obstruct  the  ostium.  In  salpingitis,  the  ostium  is  obstructed,  incompletely 
at  first,  by  the  swelling  of  the  mucous  membrane  which  involves  the  fimbrite, 
but  permanently  in  other  cases  by  great  infiltration  of  the  submucous  tissue 
and  middle  coat,  which  swell  over  the  ostium  and  cover  in  the  fimbrise.' 

He  has  drawn  attention  to  the  '  crumpling  up '  of  the  meso-salpinx  by 
inflammatory  adhesions,  and  the  consequent  approximation  of  a  distended 
tube  to  the  ovary.  '  Salpingitis,'  he  says,  '  with  obstruction,  brings  the  tube 
and  ovary  into  more  intimate  relations.  The  distended  tube  opens  up  the 
layers  of  the  meso-salpinx  until  its  walls  touch  the  ovary,  just  as  a  burrowing 
ovarian  cyst  opens  up  the  same  serous  layers  until  iis  walls  touch  the  tube. 
A  broad  ligament  cyst  burrows  in  the  same  manner  till  it  touches  the  tube 
above   and   the   ovary   below.      This   process,   which  may  be   termed   the 

*  Transaction^  Obstet.  Soc,  vol.  xxxi..  1889. 


654 


DISEASES   OF   WOMEN. 


burrowing  of  the  tube,  can  be  readily  demonstrated  on  an  ordinary  hydro- 
salpinx.   Monprofit,  who  has  described  the  process  with  great  accuracy,  terms 

it  le  dedoublement  du  mesosalpinx. 


The  reason  that  the  ostium  is  more 
or  less  permanently  closed  is  easily 
explained.  It  is  occluded  either  by 
bands  of  lymph  which  cover  in  the 
fimbriae,  or   by   changes  within  the 


Fig.  449. — Completl  OBbTEucTiON  of 
THE  Ostium,  the  Kesult  of  Salpin- 
gitis.    (Alban  Dok'va  ) 

The  end  of  the  tube  has  been  detached 
from  the  ovary  below  iiud  the  ostium 
forcibly  opened ;  a  bristle  passes  out 
of  its  orifice.  The  tissues  of  the 
tube  have  swollen  over  the  ostium, 
completely  concealing  the  fimbrise, 
excepting  the  ovarian  fimbrise,  which 
are  seen  below  the  bristle.  Behind 
and  above  the  bristle  are  perimetric 
bands,  which  must  not  be  mistaken 
for  fimbriae. 


Fig.  450.— An  Ovary  and  Tube, 
SHOWING  Obstruction  of  the 
Ostium  by  Perimetritic  Deposit, 
WHICH  forms  a  Deep  Pouch. 
(Alban  Doran.) 

The  fimbrise  have  been  partly  pulled 
out  of  the  pouch.  A  bristle  passes 
into  the  pouch  out  of  the  ostium. 


walls  of  the  tube,  which  cause  much  swelling,  so  that  they  bulge  and  close 

in  over  the  fimbriEe.  The  first  process 
is  essentially  a  part  of  the  pathological 
changes  constituting  perimetritis.  I 
shall  therefore  term  it,  for  the  sake  of 
simplicity,  '  perimetritic  closure  of  the 
ostium.'  The  second  process  is  a  part 
of  the  condition  known  as  salpingitis, 
and  may  be  termed  '  salpingitic  closure 
of  the  ostium.'  As  perimetritis  and 
salpingitis  are  often  combined,  both 
generally  take  a  share  in  closing  the 
ostium.' 

'  Perimetritic  closure  is  the  simpler 
form.  A  little  deposit  covering  the 
delicate  fimbrise  as  they  lie  on  the  sur- 
face of  the  outer  aspect  of  the  ovary  is 
sufficient  to  bind  them  down,  and  then 


Fig.  451  — Ostium  uf  Xorm\l  Fal- 
lopian Tube  laid  open,  showing 
•  THE  Continuation  of  Plic^  into 
Fimbria,  and   the   Dichotonous 
Division  op  the  Fimbria. 


The  ovarian  fimbrise  are  well  formed 

the  ostium  necessarily  becomes  closed '  as  soon  as  the  deposit  is  organized 


PLATE    LVI. 


PLATE    LYir. 


Adxexal  TrjiouRs. 

The  right  tube  (Plate  LVI.)  is  much  dilated  nnd  presents  an  omega  ioo]i, 
the  two  limbs  of  the  loop  being  closely  united  together  and  blended  with 
the  ovary,  so  that  no  mesosalpinx  is  apparent.  The  loop  of  tube  measures 
8  cm.  Tlie  fimbriated  external  and  the  uterine  cut  ends  lie  side  by  side, 
both  being  attached  to  the  ovary,  which  lies  immediately  beneath.  The 
ovary  contains  a  blood  cyst.  Its  vertical  diameter  measures  2  cm.  Its 
surface  is  roughened  by  adhesions,  and  presents  a  rupture  produced 
possibly  in  separating  the  adhesions  at  the  time  of  operation. 

The  left  tube  and  ovary  (Plate  LYII.)  present  a  fused  mass,  of  smaller  size  than 
that  on  the  right  side.  The  tube  is  gradually  distended,  from  the  uterine 
to  the  distal  extremity.  Tiie  abdominal  ostium  is  closed,  being  sealed  to 
the  ovary. 

A  careful  microscopical  examination  of  these  tubes  and  ovaries  presented  all 
the  appi-arances  present  in  chronic  salijingo-oophoritis.  the  tube  at  the 
left  side  being  incorporated  with  the  tissue  remains  of  a  contracted  and 
thickened  mesosalpinx,  wliile  the  corresponding  ovary  was  a  typically 
sclerosed  ovary  with  all  the  characteristic  appearances  seen  in  old  standing 
chronic  ovaritis.  In  the  right  ovary  there  was  cystic  degeneration,  and  the 
appearances  presented  were  those  of  commencing  ovarian  adenoma.    (C.  L.) 

[To  face  p.  654. 
(See  over  page.) 


OPESATION  (PLATES  LVI.,  LVIL). 

Appearances  presented  when  the  Abdomen  was  opened,  and  the  Steps 
necessary  for  the  Eemoval  of  the  Embedded  Adnexa — Notes  taken  at 
the  Operation. 

Left  tube  could  be  traced  to  the  outer  extremity.  Uterine  cornua  greatly 
hypertrophied,  aud  the  uterine  fibres  continuous  with  the  uterine  end  of 
the  tube  for  some  distance.  Omentum  and  bowel  adherent  to  the  plastic 
layers  covering  the  broad  liganjent.  The  ovary  is  covered  by  this  layer, 
and  is  not  visible,  but  could  be  felt.  At  the  right  side  neither  tube 
nor  ovary  were  to  be  seen.  A  smooth  membranous  covering  concealed 
both;  tracing  the  broad  ligament  out  to  the  pelvic  wall  at  its  outer  side  a 
large  mass  could  be  felt,  apparently  betsveen  the  layers  of  the  broad  liga- 
ment. At  the  left  side  the  adhesions  of  bowel  and  omentum  having  been 
separated,  the  tubo-ovarian  vessels  were  tied  off  and  the  broad  ligament 
clamped  with  Bilroth's  and  Kocher's  clamp,  one  close  to  the  uterus.  The 
thickened  cornn  and  the  ligament  were  secured,  aud  the  adnexal  mass 
removed.  At  this  side,  a  large  branch  of  the  uterine  artery  was  divided  in 
order  to  get  well  below  the  mass.  At  the  right  side  the  separation  of  the 
mass  was  more  difficult,  as  it  was  more  embedded  aud  incorporated  with 
the  broad  ligament,  the  upper  two-thirds,  which  had  to  be  removed  with 
it.  This  ovary  was  also  cystic,  and  its  contents  were  sanguineous.  The 
tube  was  like  the  left  one,  and  its  uterine  end  enormously  thickened,  and 
the  uterine  cornu,  as  in  the  other  case,  also  hypertrophied.  Patient  made 
an  excellent  recovery. 


PLATER   LVTTI.,  LTX.,  am.  LX. 


Adherunt  udnexa 

removed  by  salpiogo- 
ooijhorectomy.     At 

the  left  side  desqua- 
mative salpingitis 

with  cirrhotic  ovary. 

At  the  right  side  an 
ovarian  blood-cyst 
and  desquamative 

salpingitis.     The  en- 
tire adnexa  of  this 

side  were  embedded 
in  adhesions,  and 
were  incorporated 

with  the  broad  liga- 
ment, which  had  to 

be  divided  as  far  as 

the  uterine  artery  in 

order  to  remove  the 
mass. 

Uninterrupted 
recovery. 


J^EFI 


Right  Adnexa. 


Posterior  Aspect  of  M.^ss,  with  Aprox  of  Excdatiox. 
(See  over  page  for  description.) 


Histological  Report  (Plates  LIX.,  LX.)- 

The  right  tumour  consists  of  a  portion  of  the  right  tube,  attached  to  which  is  the 
corresponding  meso-salpins  and  a  portion  of  the  ovary  of  this  side,  together 
with  many  adhesions.  Apart  from  the  above  there  is  a  "blood-cyst."  The 
latter  iits  into  the  severed  ovary  without  any  apparent  loss  of  tissue.  The 
adhesions  mentioned  are  extensive  enough  to  cover  the  two  structures  like 
an  apron  when  they  are  placed  in  apposition.  Tlie  tube  is  enlarged 
slightly ;  it  measures  10  cm.  in  length  and  1  cm.  in  diameter.  It  is  invested 
by  adhesions,  which  pass  off  from  its  attached  border,  and,  concealing  the 
meso-salpinx,  run  downwards  to  cover  the  ovary  and  cyst.  'J'hese  adhesions 
have  dragged  up  the  ovary  towards  the  tube,  thus  causing  a  shortening  and 
thickening  of  the  meso-salpinx.  A  section  of  the  tube  shows  a  thickened 
serosa,  and  a  similar  condition  of  desquamation  of  the  cubical  epithelium 
of  the  swollen  plicse  as  was  observed  in  the  tube  of  the  opposite  side.  The 
ovary  shows  a  thick  investmeut  of  fibrous  lymph,  and  a  densely  infiltrated 
stroma.  The  wall  of  the  blood-cyst  is  lined  by  festoons  of  lutein  cells, 
showing  that  it  arose  from  a  ripe  corpus  luteum.  It  is,  in  fact,  a  lutein 
cyst.    (Cuthbert  Lockyer.) 

\_To  face  p.  655 


AFFECTIONS  OF  THE   FALLOPIAN   TUBES.  (J55 

In  operations  for  chronic  disease  of  the  appendages  the  early  stage  of  the 
process  is  often  observed.  Sometimes,  on  scraping  away  the  bands  of  the 
lympii,  the  fimbriae  come  in  sight,  well  formed,  succulent,  and  bright  red, 
being  full  of  blood.     In  that  case  little  ur  no  salpingitis  is  present.' 

Relation  of  Salpingitis  to  Perimetritis. 

I  have  already,  in  discussing  the  etiology  of  parametritis  and 
perimetritis,  referred  to  the  various  other  causes  that  may  lead 
up  to  a  combined  inflammation  of  both  ovaries  and  tube.  In  fact, 
tin;  more  we  l-noio  of  the  patholtK/y  of  perimetric  inflammation  (jenerallt), 
the  more  obvious  is  it  that  these  four  affections — metritis,  perimetritis, 
salpintjitis,  and  ovaritis — are  often  correlated  and  consequent  on  each 
other,  and  that  all  four  are  frequently  associated  and  concurrent. 
Endometritis  leads  to  catarrhal  salpingitis,  which  in  its  turn  is  the 
precursor  of  hydro-salpinx  or  pyo-salpinx.  The  ovary  is  next 
involved,  and  pi'obably  becomes  adherent,  and  a  communication 
takes  place  between  the  parenchyma  of  the  latter  and  the  suppura- 
ting tubal  cavity.  It  is  rare  to  lind  isolated  salpingitis  or  ovaritis 
without  some  correlative  inflammatory  condition  of  either  tube, 
ovary,  or  uterus. 

There  is  good  ground  for  Pozzi's  division  into  oophorosalpingitis,  wliich 
includes  inflammation  of  the  ovaries  and  Fallopian  tubes ;  cystic  oophoro- 
salpingitis, including  hydro-salpinx,  hsemato-salpinx,  and  pyo-salpinx,  as  well 
as  cystic  ovaritis,  whether  of  the  serous,  sanguineous,  purulent,  or  lymphatic 
type.  Also  the  term  perimetric  salpingitis  is  made  by  this  author  to  include 
perimetritis  with  phlegmon  of  the  broad  ligaments  cellulitis,  and  pelvic  abscess, 
of  which  I  have  ali'eady  spoken. 

General  Deductions. — From  all  that  has  been  observed  and 
written  on  this  subject  I  repeat  that  the  great  practical  lessons  we 
learn  are  :  Firstly,  that,  as  chronic  uterine  inflammatory  states  arc  the 
frequent  forerunners  of  inflammation  of  the  adnexa,  it  is  a  grave  error 
to  trifle  with  these,  and  go  on  with  expectant  measures  for  an  indefinite 
time  in  cases  of  endometritis  in  any  form.  Secondly,  that  morhid 
conditions  of  the  Fallopian  tubes  and  ovaries  are  more  frequently 
present  than  absent  in  perimetritis  and  peri-uterine  phlegmon.  Thirdly, 
that  in  serious  disease  of  the  adnexa  all  experience  teaches  us  that  the 
postponement  of  active  methods  of  treatment — by  waiting  on  nature  and 
trusting  to  such  means  of  cure  as  prolonged  rest,  hot  douching,  tampons, 
intra-uterine  medication,  or  aspiration — is  only  putting  off  the  time  when, 
under  much  more  unfavourable  circumstances,  operation  of  one  hind  or 
the  other  has  to  be  resorted  to. 


656  DISEASES   OF    WOMEN. 

Pathology." 

Acute  salpingitis,  arising  in  the  tubal  mucous  membrane,  may 
pass  into  a  chronic  state,  or,  the  cause  being  of  an  infective  nature, 
such  as  gonorrhceal  or  puerperal  inflammation,  the  entire  thickness 
of  the  tubal  wall  is  quickly  involved,  including  the  connective  inter- 
muscular tissue,  which  becomes  cedematous.  Possibly  a  miliary 
abscess  forms  (Boldt),  and  finally  pyo-salpinx,  or  it  may  end  in 
contraction  and  sclerosis.  The  epithelial  lining  may  be  preserved, 
while  the  wall  of  the  tube  is  thus  thickened. 


Endo-salpingitis. 

In  endo-saljnngitis  the  main  brunt  of  the  attack  falls  on  the 
mucous  lining.  This  is  a  true  catarrhal  state,  and  may  lead  to 
suppuration.  Gradually  in  shape  and  size  the  tube  is  altered,  and 
its  caKbre  is  obstructed.  The  secretion  it  contains  may  be  serum, 
mucus,  or  pus.  Such  naked-eye  appearances  are  attended  by  corre- 
sponding changes  in  the  microscopical  features  of  the  tissues.  The 
mucous  folds,  thickened  and  reduplicated,  are  in  parts  united  by 
exudation.  The  epithelial  elements  are  disposed  in  irregular  masses 
around  the  depressions.  In  the  simjile  catarrhal  state  the  epithelia 
and  their  nuclei  are  swollen.  The  mucous  lining  is  cedematous,  and 
infiltrated  with  white  blood-cells ;  the  vessels  ai"e  dilated  and 
engorged.  The  same  conditions  prevail  in  the  pixrulent  variety, 
save  that  there  is  a  more  active  diapedesis,  and  the  epithelial 
elements  are  separated  by  the  transuding  blood-cells. 

Parenchymatous  Salpingitis. 

In  parenchymatous  salpingitis,  which  may  be  secondary  to  the 
acute  endo-salpingitis,  the  lumen  of  the  tube  is  encroached  on ;  the 
wall  becomes  harder.  Its  fimbriated  end  is  changed  in  appear- 
ance. The  advancing  sclerosis  gives  to  the  mucous  surface  a  smooth 
feel  and  look.  The  result  is  a  chronic  hypertrophic  condition,  in 
which  pseudo-membranous  laminse  of  tissue  are  formed,  and  fibrous 
layers  are  scattered  between  the  normal  muscular  fibres.  These 
contract  the  lumen  of  the  canal,  which  is  still  further  narrowed  by 
the  thickened  villi,  clothed  with  elongated  cylindrical  epithelium. - 

*  I  am  indebted  to  Bonnet  and  Petit  Qib.  cit.)  for  much  of  tlie  pathological 
anatomy  of  the  Fallopian  tubes. 


AFFECTIONS  OF  THE  FALLOPIAN   TUBES.  657 

Chronic  Atrophic  Salpingitis. 

In  the  final  stage  of  this  sclerotic  change,  we  arrive  at  the  form 
of  connective-tissue  development  that  obliterates  the  muscular  tissue 
and  the  vessels,  and  greatly  reduces  the  lumen  of  the  tube  or  closes 
it  altogether.  This  atresic  state  is  preceded  by  an  atrophy  of  the 
cilia,  and  is  the  last  stage  of  the  chronic  atrophic  degeneration  so 
well  described  by  Bonnet  and  Petit. 

Tait  drew  a  distinction  between  the  salpingitis  that  mainly  affects  the 
mucous  lining  (endo-salpiugitis)  and  that  which  attacks  the  substance 
(parenchymatous)  of  the  tubes.  Thelatter  is  by  far  the  more  common.  As 
a  result  we  have  severe  dysmenorrhcea  before  and  during  a  period  ;  at  times 
there  is  a  history  of  gonorrhoeal  inflammation,  a  miscarriage,  or  a  zymotic 
fever. 

There  is  frequently  extreme  dyspareunia.  I  have  had  several  such  cases, 
one  occurring  in  a  patient  in  whom  most  severe  vaginitis  and  metritis  were 
induced  by  the  forcible  introduction  under  chloroform  of  a  large  ring  pessary, 
which  unfortunately  was  permitted  to  remain  in  until  it  had  to  be  removed 
under  an  ansesthetic. 

The  sphincter-like  action  of  the  muscular  fibres  surrounding  the 
uterine  opening  of  the  tube  has  to  be  remembered.  Arrest  or 
destruction  of  the  function  of  these  fibres  has  an  important  bearing 
on  the  entrance  of  fluids  into  the  peritoneal  cavity,  and  on  the 
danger  of  intrauterine  medication.  "We  can  readily  understand  how 
the  sphincter  action  is  arrested  in  severe  post-partum  heemorrhage, 
and  destroyed  in  diseased  conditions  of  the  endometrium,  or  from 
the  growth  of  tumours  in  the  adjacent  muscular  structure  of  the 
uterus. 

Gonorrhoeal  Salpingitis. — Gonorrhoea  and  the  presence  of  the 
gonococcus  as  a  source  of  salpingitis  is  more  frequent  than  is  generally 
thought.  The  inflammatory  consequences  in  the  adnexa  may  have 
their  source  clearly  indicated  by  the  character  of  the  inflammation 
which  has  preceded  them  in  the  ui*ethra,  vulva,  and  vagina.  Such 
symptoms  may  follow  acutely  on  the  inflammation  of  the  external 
genitals  and  vagina,  or  the  afiection  may  subside  or  be  apparently 
cured,  and  the  latent  infection  not  manifest  itself  in  the  pelvic 
viscera  until  a  period  varying  from  weeks  to  months  has  elapsed. 
In  a  great  number  of  cases  we  are  only  led  to  suspect  the 
source  of  the  salpingitis  by  the  character  of  the  discharge  from 
the  uterus,  which  is  generally  virulent  or  profuse,  and  the  frequent 
involvement  of  l)Oth  adnexa.  In  other  cases,  however,  the  nature 
of    the    original    affection   and    its    symptoms   have   possibly  been 

2  u 


658  DISEASES   OF    WOMEN. 

forgotten  by  the  patient,  or,  in  the  first  instance,  of  so  mild  a 
character  that  they  have  been  overlooked,  and  we  are  confronted  with 
a  pyo-salpinx  and  some  slight  endometritic  suppurative  discharge  in 
which  the  specific  microbe  may  not  be  discovei'ed  even  after 
repeated  cultures,  though  we  have,  on  inquiry',  elicited  from  the 
husband  sufficient  evidence  to  confirm  us  in  our  suspicion  that 
gonorrhcea  is  the  cause  of  the  salpingitis.  The  percentage  of  cases 
of  pyo-salpinx  due  to  gonorrhcea  has  been  variously  estimated,  many 
authorities  placing  it  at  so  high  an  estimate  as  33  per  cent, 

Gonococci  in  the  Tubal  Walls. — Knauer,  Bumm,  aud  Wertheim  have  found 
gonococci  deep  in  the  tubal  walls.  'J'bey  may  make  their  way  either  from 
the  lumen  of  the  tube  or  from  the  peritoneal  surface.* 

Alexander  Foulerton,  who  has  devoted  special  attention  to  the  bacteriology' 
of  gonorrhoea,  in  sixteen  cases  of  pyo-salpinx  found  the  micro-coccus  gonorrhoea 
with  the  staphylococcus  pyogenes  albus  and  the  bacillus  coli  communis  each 
in  two  cases,  and  the  streptococcus  in  one.  The  bacillus  tuberculosis  was 
also  discovered  in  two  cases,  and  in  the  remainder  no  microbe  was  found. 
Collecting  the  statistical  results  in  459  cases  of  salpingitis  examined,  he 
found  that  the  gonococcus  had  been  identified  in  eight^'-five  cases,  or  about 
19  per  cent.  In  about  60  per  cent,  no  micro-organism  of  any  kind  had 
been  identified  in  the  contents  of  the  tube.  He  accounted  for  the  absence  of 
the  micro-organism  in  so  large  a  proportion  of  cases  by  the  fact  that  many 
of  them  did  not  come  under  observation  until  such  a  late  time  in  the  duration 
of  the  afiection  that  the  causative  bacteria  had  died  out,  starved  for  want  of 
nourishment  or  poisoned  by  their  own  excretory  products. 

Many  cases  of  jiyo-salpinx  owe  the  presence  of  certain  bacteria  to 
secondary  infection  from  some  other  cause  than  the  inflammation  in  the  tube, 
as,  for  example,  the  adhesions  formed  between  a  tube  already  inflamed  and 
an  adjacent  portion  of  intestine.  The  gonococcus,  taking  only  those  cases 
in  which  the  cause  could  be  proved  by  pathological  research,  was  present  as 
the  causative  parasite  in  considerably  more  than  half  such.  Further,  he 
considered  this  estimate  as  less  than  was  actually  the  case,  if  we  take  the 
light  thrown  on  the  subject  by  clinical  observation.  Ure  thro -vulvitis  or 
eudocervicitis  were  the  earliest  manifestation  of  gonorrhceal  infection.  In 
489  cases  in  which  the  vulvar  discharge  was  examined,  the  gonococcus  was 
found  in  323,  that  is,  in  about  6%  per  cent.,  whereas  the  organism  was  only 
found  54  times  in  680  cases  in  which  the  purely  vaginal  discharge  was 
examined,  that  is,  in  about  8  per  cent. 

These  statistics  and  observations  of  Foulerton's  endorse  the  views  of  the 
majority  of  gynajcologists  as  to  the  potent  influence  of  gonorrhoea  in  causing 
chronic  suppurative  endometritis  and  salpingitis,  but  they  also  bear  on  the 
very  important  clinical  feature  of  the  gonorrhceal  infection,  namely,  that  it  is 
in  the  uterus  and  Fallopian  tubes,  rather  than  in  the  vagina,  that  the 
specific  inflammation  first  manifests  itself.     This  latter  clinical  fact  had  been 

*  Monats.f.  Geb.  und  Gyn.,  Aug.,  1902, 


PLATE    LXI. 


True  Tcbo-ovaeiax  Ctst.  (J.  Taylok.) 
opening  of  the  Fallopiaa  tube.  True  tubo-ovaiian  cyst  of  the  left  side 
removed  by  posterior  vaginal  cceliotomy  on  January  21.  1904.  The  patient 
was  31  years  of  age,  married,  and  had  had  a  smaller  tubo-ovarian  cyst  (of 
the  right  side)  removed  five  years  previously  by  the  same  method.  The 
fluid  of  the  cyst  was  slightly  brownish,  and  tinted  as  if  mixed  with  a  little 
blood,  a  secretion  from  the  tube.  Xo  adhesions.  lodoform-gauze-drainage 
of  Douglas.     Kecovery. 

[^Tofacep.  6.58 


PLATE   LXII. 


Outer  Sukpace  of  the  Cyst,  with  the  Incoepoeated  Fallopiax  Tube. 
Tubo-ovariaii  Cyst. 

[To  face  jj.  659. 


AFFECTIONS  OF  THE  FALLOPIAN  TUBES. 


65D 


accountod  for  by  several  authorities  by  the  nature  of  the  vaginal  epitheliiun, 
which  resists  the  invasion  of  the  gonococcus. 

Syphilis. — John  Taylor  has  noticed  in  cases  that  have  come  under  his 
observation  the  more  or  less  frequent  association  of  syphilis  with  the  gonor- 
rhccjt,  and,  acting  on  this,  he  has  administered  mercurial  treatment  with  a 
good  result  in  several  instances.  Further,  he  favours  the  free  opening  of  pus 
cavities  without  salpingo-oophorectomy  or  ablation  of  the  pyo-salpinx,  limited 
to  one  side  only  should  the  adnexa  of  the  other  be  healthy.  The  contamina- 
tion of  gonorrhteal  pyo-salpinx  by  infection  from  the  neighbouring  bowel 
renders  the  case  more  serious.* 

SutHcient  has  been  already  said  of  the  methods  of  dealing  with 
pelvic  suppurations  to  make  it  unnecessary  to  refer  again  to  the 
latter.  The  best  mode  of  reaching  and  extirpating  a  pyo  salpinx 
must  always  be  determined  by 
the  local  conditions  found  asso- 
ciated with  it.  There  will  ever 
be  cases  in  which  the  only 
resort  left  to  the  surgeon  is 
hystero-salpingo  -oophorectomy, 
generally  best  eftected  by  the 
vaginal  route. 

Tubo-ovarian  Cysts. f— This 
name  is  given  to  a  condition  in 
which  the  lumen  of  the  Fal- 
lopian tube  communicates  di- 
rectly with  the  interior  of  an 
ovarian  cyst.  The  fimbriated 
end  of  the  tube  is  often  found 
spread  over  the  inner  wall  of 
the  cyst.  Two  varieties  must 
be  distinguished ;  the  first  is 
due  to  inflammatory  changes, 
and  probably  first  appears  in 
most  instances  as  a  tubo- 
ovarian  abscess,  the  contents  of 
which  then  become  sterile,  in 
much  the  same  way  as  a  hydro- 
salpinx arises  from  a  pyo-salpinx.  It  is  doubtful  whether  a 
tubo-ovarian  cyst  ever  arises  simply  from  the  communication  of  a 
tube  with  an  ovarian  cyst  without  any  process  of  suppuration.     A 

*  See  p.  657,  GonorrhcBal  Pyo-salpinx. 

t  See  also  chapters  on  the  Ovaries  and  Tuberculosis. 


Fig.    452.  —  Tubo-ovakian    Cyst   fkom 
THE  Eight  Side.     (Howard  Kelly.) 

The  uterine  tube  crosses  the  C}st  in  the 
form  of  an  co;  at  its  right  extremity 
it  is  kinked  and  adherent  to  a  jMeuc 
of  the  uterine  cornu  which  has  been 
excised  with  the  tumour.  The  tube 
ends  in  the  domelike  prominence  above 
and  to  the  left.  A  small,  clear  sub- 
peritoneal cyst  marks  the  border  line 
between  the  ovarian  cyst  and  the  tube. 
i  nat.  size. 


660  DISEASES   OF   WOMEN. 

tubo-ovarian  cyst  presents  a  characteristic  retort-shaped  mass ;  the 
aperture  of  communication  is  generally  wide,  and  is  seen  on  section 
to  be  surrounded  by  the  tubal  fimbriae.  The  second  variety  is  of 
congenital  origin,  and  is  not  a  true  tubo-ovarian  cyst,  but  the  con- 
dition described  by  Bland-Sutton  as  an  ovarian  hydrocele.  In  this 
case  the  tube  communicates,  not  with  the  interior  of  the  ovary,  but 
with  a  peritoneal  pouch  which  surrounds  the  ovary  like  the  tunica 
vaginalis  round  the  testis.  If  the  mouth  of  the  peritoneal  recess  in 
which  such  an  ovary  lies  becomes  occluded  by  adhesions,  the  jjseudo- 
tuho-ovarian  cyst  results.  The  wall  of  the  cyst  is  not  here  formed  by 
a  cystic  ovary,  but  this  gland  is  found  lying  up  against  the  inside  of 
one  portion  of  the  cyst-wall.  It  is  better  to  use  the  term  ovarian 
hydrocele  for  this  condition,  restricting  the  term  tubo-ovarian  cyst 
to  the  variety  of  inflammatory  origin.  It  is  generally  impossible 
to  tell  from  external  appearances  alone  with  which  kind  of  cyst 
we  have  to  deal ;  this  can  only  be  determined  on  opening  it.  A 
third  condition  whose  external  appearance  resembles  a  tubo-ovarian 
cyst  is  also  found  ;  namely,  a  large  hydro-salpinx  matted  to  the 
ovary  by  adhesions  here.  Careful  separation  of  the  adhesions  will 
show  that  the  ovary  is  quite  distinct  from  the  tube. 


Fig.  458.— Tobu-ovaeiax  Cyst  laid  opkn;   Fimbria   are   seen   on   the   In- 

TEKIOR    OF    THE    CyST   WaLL     FORMING    THE    SO-CALLED    '  OvARIAN    HYDRO- 
CELE.'    (Howard  Kelly.) 

Eeymond  and  Magill  *  made  exhaustive  researches  into  the  macroscopic 
characters  of  salpingo-ovaritis,  the  microscopic  lesions  of  each  tissue,  the 
nature  of  the  salpingitis  produced  by  the  gonococcus,  streptococcus,  and 
A'arious  other  micro-organisms. 

Ostium  IJteri. — Macroscopically,  the  ostium  uteri  was  frequently  found 
impermeable  from  changes  in  the  tubal  walls  producing  stenosis,  also  from 
external  pressure,  and  from  bends; 

*  Annals  of  Surgery,  Sept.  and  Oct.,  1896. 


AFFECTIONS  OF  THE  FALLOPIAN   TUBES.  0(51 


The  Pavilion.— Tlie  abdominal  ostium  was  closed  from  changes  occurring 
in  the  peritoneal  covering,  adhesions  between  the  fringes,  ending  finally  in 
obliteration  of  the  latter,  or  the  adherence  of  the  pavilion  to  the  ovary,  its 
fringes  spreading  out  over  it,  so  that  the  ostium  is  turned  away  from  it. 

Reymond  and  INIagill  account  for  a  tubo-ovarian  cyst  by  the  physiological 
predilection  of  the  pavilion  to  approach  an  ovisac,  and  when  an  ovarian  cystic 
collection  takes  tlie  place  of  tlie  latter  it  naturally  is  drawn  towards  it  in  the 
same  manner.  The  time  of  closure  of  the  pavilion  in  its  relation  to  adliesions, 
and  the  extent  to  which  these  have  formed,  will  influence  the  collection  of 
fluid  in  a  sacto-salpinx  and  its  relation  to  the  ovarian  tissue. 

In  salpingo-ovaritis,  the  ovarian  cavity  is  frequently  transformed  into  a 
large  cyst,  smaller  ones  being  disseminated  through  the  walls.  Such  cysts 
open  into  the  salpinx.  They  may  contain  serum  or  pus,  and  this  purulent 
formation  may  occur  independently  of  any  contact  with  the  tube.  The 
duration  of  the  ovaritis  will  affect  both  the  nature  of  the  contained  fluid  and 
the  size  of  the  communication  between  the  tube  and  ovary.  A  localized 
peritonitis  may  give  rise  to  an  intermediary  cavity  between  the  tube  and  ovary. 

Preiss'  definition  of  a  tubo-ovarian  cyst  is  '  a  cystic  tumour  of  the  uterine 
adnexa,  in  the  formation  of  the  walls  of  which  both  tube  and  ovary  take  part.' 
Tlie  most  usual  form  is  the  retort- shaped.  The  wall  of  the  distended  tube, 
the  finibrire  being  absent,  are  continued  directly  into  that  of  the  ovarian  cyst- 
But  there  may  be  an  intermediate  cyst  with  persistent  fimbrise,  free  or 
adherent,  inside  the  tubo-ovarian  one.  Signs  of  inflammation  are  generally 
present.  Preiss  does  not  believe  in  the  existence  of  the  congenital  condition 
called  ■  ovarial  tube.'  He  contends  that  the  majority  of  tubo-ovarian  cysts 
are  the  consequence  of  the  adhesion  of  a  salpingeal  sac  with  the  ovarian 
cyst,  and  the  subsequent  disappearance  of  the  fimbria?,  the  septum  separating 
from  pressure.     It  may  also  be  due  to  a  hsematocele. 

Adhesions.— With  regard  to  adhesions  between  the  neighbouring  viscera 
and  the  adnexa,  Magill  and  Reymond  notice  that  the  omentum  may  be 
transformed  into  a  thick  hard  mass  of  dark  red  colour,  and  very  vascular. 
Fatty  degenerations  pass  into  inflammatory,  organized,  and  cicatricial  tissues, 
and  the  blood-vessels  give  rise  to  thrombus  and  interstitial  hajmorrhages. 
Adhesions  of  the  adnexa  to  the  intestine  at  the  right  and  left  sides  are 
common,  and  such  adhesions  are  associated  with  the  passage  of  micro- 
organisms from  the  intestine,  which  infect  the  salpinx  secondarily.  Absorp- 
tion of  intervening  tissues  may  give  rise  to  a  communication  between  the 
salpingitis  and  the  intestine.  At  the  right  side  such  infection  may  lead  to 
a  primary  typhlitis  and  appendicitis.  In  the  same  manner  communications 
may  occur  between  the  bladder  and  the  salpinx. 

Classification  of  Salpingitis. 

Magill  and  Reymond  divide  salpingitis  under  two  heads — Classical  and 
Rare.  The  classical  would  include  Orthmann's  division  into  catarrhal, 
puruhnf,  hematosalpinx,  hydrosalpinx,  and  pyosalpinx.  Cornil  adds 
fnberculur  salpingitis,  and  speaks  of  a  '  vegetating  catarrhal  salpingitis.^ 
Pozzi's   classification   has   already   been   given.     Under   the  rare  forms  are 


662  DISEASES   OF   WOMEN. 

included  tlie  vegetating  salpingitis  of  Cornil,  wbicli  is  of  a  parenchymatous 
nature,  papillomatous  salpingitis  (described  by  Doran),  follicular  salpingitis, 
in  which  there  is  an  isolation  of  glandular  cul-de-sacs,  forming  closed  cavities 
at  first  found  in  the  mucous,  and  later  on  in  the  muscular  tissue. 

Nodular  Salpingitis  has  by  different  authorities  been  looked  upon 
as  myoma  of  the  salpinx.  In  such  cases  the  lumen  of  the  tube  is 
contracted,  and  the  myomatous  change  is  fovmd  immediately  outside 
it,  the  ordinary  disposition  of  the  muscular  fibres  being  lost,  while 
cysts  are  disseminated  through  the  muscular  tissue,  or  the  latter  is 
replaced  by  fibrous  tissue.  This  admixture  of  muscular  and  cystic 
degeneration  occurs  in  varying  degrees  of  intensity  in  the  thickened 
walls  of  the  tube.  Such  degeneration  gives  place  in  parts  to  fibrous 
change,  and,  consequently,  we  find  these  various  transformations 
invading  the  mucous  membrane.  Thus  we  see  how  a  mixed 
form  of  degeneration  may  thicken  the  walls  of  the  tube  and  con- 
bract  its  lumen. 

Dermoid  in  the  Fallopian  Tube. 

Orthmann  *  recorded  a  case  in  which  a  patient  who  had  undergone  curet- 
tage, amputation  of  the  cervix,  and  vaginal  fixation,  suffered  from  irregular 
liferaori-bage,  for  which  she  was  curetted  a  second  time.  After  this  the  right 
adnexa  were  removed,  as  a  sacto -salpinx  at  that  side  was  diagnosed.  The 
tube  was  found  to  contain  hair,  detritus,  and  a  tooth-like  body  of  cartilaginous 
consistence.     By  microscopical  examination  germinal  epithelium  was  found. 

Calcification  of  the  Adnexa  in  Pyo-salpinx. 

Ries  of  Chicago  f  has  reported  three  cases  of  calcified  pyo- 
salpinx  and  hydro-salpinx.  They  consisted  of  fibrous  matter,  fat, 
cholesterin,  carbonate  and  phosphate  of  lime  and  magnesia.  They 
were  possibly  due  to  retrograde  metamorphosis  in  the  corpora  lutea, 
or  from  cysts  of  these. 

Hsemato-salpinx  not  of  Ectopic  Gestation  Orig-in. 

Bland-Sutton  showed  at  the  Obstetrical  Society  a  case  of  an 
ovary  which  contained  a  calcific  mass  projecting  from  the  wall  of 
the  cyst,  and  which  enclosed  an  incapsuled,  lobulated  piece  of  hard 
bone  like  tissue,  similar  to  those  masses  which  are  found  in'  old 
uterine  myomata. 

*  Centmlb.  f.  Gyn.,  Dec,  1902.         f  Zeitschrift.  f.  Geh.  u.  Gyn.,  1899. 


^^v. 


~     "^ 


X 


< 

PL, 


V 


-/I        o     to 


O       3 

;2;  ^ 


AFFECTIONS  OF  THE  FALLOPIAN  TUBES. 


663 


Fig.  4.".4. — ILijmourhage  into  Fallopian"  Tube  not  due  to  Ectopic 
Gestatiox.    (Albax  DonAx.) 


Fig.  4.").!. — HxE^muiiHAGE  into  Uterine  Cavity  and  Fallopian  Tube  not 
DUE  TO  Ectopic  Gestation.    (Griffiths.) 


664  DISEASES    OF    WOMEN. 

An  interesting  case  of  haemorrhage  from  the  Fallopian  tube 
without  evidence  of  tubal  gestation  is  that  recorded  by  Doran.* 

The  tumour  was  removed  as  a  reddish-brown  solid  mass,  into 
which  the  right  Fallopian  tube  appeared  to  run.  It  was  adherent 
posteriorly  to  the  sigmoid  flexure  and  rectum.  The  left  adnexa  were 
healthy.  The  tumour  formed  a  pyramidal  mass  with  convex  surfaces. 
The  apex  was  firmly  incorporated  with  the  fimbriae  of  the  tube  above 
the  ostium  ;  the  base  measured  2-|-  inches.  The  interior  appeared  on 
section  as  solid  coagulum,  old  and  firm  towards  the  base,  soft  and 
recent  at  the  apex,  which  lay  close  to  the  tubal  ostium.  The 
fimbriae  of  the  tube  were  normal,  the  canal  showed  no  sign  of 
dilatation  or  inflammation,  and  the  ostium  was  not  dilated.  The 
mesosalpinx  was  perfectly  free  from  any  abnormal  condition.  The 
ovary  was  large,  two  inches  in  vertical,  and  an  inch  and  a  half  in 
transverse  diameter.  On  its  cut  surface  were  several  follicles 
about  an  eighth  of  an  inch  in  diameter,  full  of  half-decolorized  clot, 
but  a  corpus  luteum  was  not  found  (Fig.  454).  The  tube  was 
perfectly  healthy,  and  the  disturbance  recent,  while  the  ostium  was 
not  dilated,  neither  was  there  any  sign  of  obstruction  which 
might  have  given  rise  to  a  hsemato-salpinx.  In  Griffiths'  speci- 
men (Fig.  455),  the  pelvic  organs  were  removed  from  a  nullipara 
aged  18,  who  died  from  uncontrollable  epistaxis  and  menor- 
rhagia,  A  vermiform  clot  hung  out  of  the  ostium.  A  blood-clot 
which  was  contained  in  the  uterine  cavity  extended  along  the 
Fallopian  tubes,  projecting  at  the  right  side  beyond  the  fimbriated 
extremity.  In  this  case  the  peritoneum  was  normal,  and  no  blood 
had  escaped  into  its  cavity.  Here  also  there  was  no  evidence  of 
ectonic  s:estation. 


Accessory  Ostia  and  Cysts  of  the  Meso-Salpinx. 

The  report  on  the  adoexa  of  which  Fig.  456  is  a  drawing  was  furnished 
to  me  by  Mr.  Targett.  From  the  recent  researches  of  Handley  and  others, 
the  cyst  in  tliis  specimen  Avas  an  accessory  Fallopian  cyst. 

RigL.t  Uterine  Appendages. — The  Fallopian  tube,  its  ostium  and  fimbriae, 
were  normal.  Attached  to  the  posterior  surface  of  the  meso-salpinx  were 
two  pedunculated  bodies  nearly  half  an  inch  long.  The  extremity  of  one  of 
these  bodies  was  dilated  into  a  small  cyst  (6),  so  that  it  resembled  a  hydatid  of 
Morgagni.  The  other  body  had  a  stouter  pedicle,  became  dilated  towards  its 
free  extremity,  and  terminated  in  a  minute  ostium  and  fimbriae  {d).  A  bristle 
could  be  inserted  into  the  ostium  for  about  an  eighth  of  an  inch.     The  body 

*  Ohstet.  Trans.,  vol.  xl.  p.  1 82. 


AFFECTIONS  OF  THE  FALLOPIAN   TUBES. 


665 


had,  therefore,  the  structure  of  an  accessory  Fallopian  tube.  The  seats  of 
attachment  of  these  pedunculated  bodies  were  very  close  together,  and  cor- 
responded in  position  with  the  horizontal  tubules  of  the  parovarium  ;  their 
development  was  probably  associated  with  these  tubules,  and  the  fimbriated 
body  might  be  regarded  as  the  persistent  end  of  the  Miillerian  duct.     The 


Fig.  45G. — Ovaries 


Meso-metria  and  Fallopian  Tubes  viewed  from 

BEHIND.       (ArTHOR.) 


ovary  showed  much  wrinkling  of  its  surfaces  at  the  upper  pole,  but  the  rest 
of  the  exterior  was  smooth  and  healthy.  On  section,  an  oval  thick-walled 
cyst  was  displayed,  which  measured  an  inch  in  chief  diameter.  It  contained 
a  little  blood-stained  fluid,  but  had  ruptured  during  removal,  hence  the  greater 
part  was  lost. 

Left  Uterine  Appendages. — The  Fallopian  tube  and  its  fimbriae  were  healthy; 
there  were  three  distinct  ostia  leading  out  of  the  ampulla  (a,  a,  a).  The 
fimbriee  on  the  edge  of  the  meso-salpinx  were  numerous,  but  appeared  healthy. 
Between  the  layers  of  the  meso-salpinx  there  were  four  small  cysts.  The 
largest  had  an  elongated  outline,  its  long  diameter  measured  nearly  one  inch, 
and  was  placed  almost  at  right  angles  with  the  axis  of  the  Fallopian  tube  (a). 
From  the  surface  of  this  cyst  sprang  a  small  pedunculated  cyst  like  a  hydatid 
of  Morgagni,  and  this  resembled  the  structure  described  in  the  right  appen- 
dages. The  remaining  two  cysts  (e)  in  the  meso-salpinx  were  the  size  of  a  pea  ; 
they  did  not  seem  to  be  connected  with  the  vertical  tubules  of  the  parovarium, 
one  being  close  on  the  edge  of  the  meso-salpinx,  and  the  other  crossed  by 
these  tubules,  but  the  abdominal  end  of  the  horizontal  tubules  might  be 


See  p.  607. 


666  DISEASES   OF   WOMEN. 


traced  up  to  the  elongated  cyst.     Hence  it  conld  have  arisen  in  connection 
with  the  extremity  of  the  Wolffian  duct. 

The  naked  appearance  of  the  left  ovary  did  not  differ  materially  from  that 
of  the  right.  Its  smface  was  less  wrinkled,  and  on  section  a  similar  cyst  was 
to  be  seen  at  one  end  of  the  organ.  This  had  ruptured  during  removal. 
There  was  another  small  cyst  in  the  substance  of  the  ovary. 

Cysts  of  Morgagni. 

With  regard  to  the  hydatid  or  cyst  of  Morgagni,  Bland-Sutton  says — 
'  This  term  is  apphed  to  a  small-stalked  cyst  attached  to  the  fimbriae,  and 
in  some  instances  to  the  tube  itself.  It  is  rarely  larger  than  a  pea.  Some- 
times it  is  represented  by  a  tuft  of  fimbrise  supported  on  a  long  pedicle. 
Occasionally  the  pedicle  of  the  cyst  is  furnished  with  a  small  tuft  of  fimbrise. 
The  true  hydatid  must  not  be  confounded  with  stalked  cysts,  so  frequently 
found  associated  with  the  parovarium.'  Ballantyne  and  Williams  have  care- 
fully investigated  the  frequency  with  which  the  true  '  hydatid '  is  present. 
They  found  stalked  cysts  in  75  per  cent,  of  specimens  examined.  The 
true  Morgagnian  cyst  was  present  in  8  per  cent,  in  adults,  and  in  27  per 
cent,  of  fcBtuses  and  infants.  The  total  number  of  tubes  examined  was  ninety- 
four  pairs  from  aduHs,  eleven  pairs  from  foetuses,  and  five  pairs  from  children. 
There  are  structural  differences  between  the  two  forms.  According  to  Bal- 
lantyne and  WilHams,  the  true  Morgagnian  cyst  '  is  lined  by  a  mucosa  with 
simple  folds,  covered  by  a  single  layer  of  ciliated  columnar  epithelial  cells  ; 
its  wall  is  always  composed  of  muscular  fibres,  arranged  circularly  and 
longitudinally ;  its  outer  membrane  is  the  peritoneum  ;  its  stalk  is  always 
muscular,  and  its  contents  consist  of  clear  liquid  fluid ;  whereas,  the  small 
pedunculated  cysts  of  the  parovarium  have  fibrous  stalks  and  walls;  the 
inner  walls  of  such  cysts  are  lined  by  cubical  epithelium.'  '  With  regard  to 
the  pedunculated  accessory  fimhrim,'  the  same  authors  say,  'they  are  probably 
derived  from  Kobelt's  tubes.  When  describing  the  parovarium,  attention 
was  drawn  to  the  pedunculated  cysts  so  frequently  found  at  its  outer  end, 
known  as  Kobelt's  tubes.  Some  of  these  small  cysts  rupture,  and,  instead  of 
a  stalked  cyst,  we  find  a  pedunculated  tuft  of  fimbria^.'  The  cysts  sometimes 
appear  as  if  growing  from  the  wall  of  the  tube ;  they  have  little  doubt  that 
the  stalked  tufts  of  accessory  fimbrise  originate  in  similarly  displaced  Kobelt's 
tubes.* 

A  distension  of  the  Fallopian  tube  with  serum,  or  a  simple  hydro- 
salpinx, must  be  kept  distinct  from  those  thickened  conditions  in 
which  temporary  collections  of  fluid  occur  in  the  sacculated  tube,  or 
when  an  ovarian  cyst  communicates  with  the  tube  of  a  tubo-ovarian 
cyst.  ■  The  latter  condition  reaches  far  greater  dimensions  than  does 
a  hydro-salpinx,  and  hence  the  confusion  which  has  arisen  as  regards 
the  occasional  size  to  which  a  hydro-salpinx  may  extend.  The 
probability  is  that,  in  the  majority  of  cases,  a  hydro-salpinx  is  the 
*  See  also  paper  by  C.  Handley,  Jour.  Obstet.  and  Gyn.,  Nov.,  1903. 


PLATE   LXIY. 

b 


POSTEEIOR    StJEFACE. 

;_See  Plate  XCIV.  for  large  left  ovarian  lisemato  cyst  removed  at  tlie  same  time. 
PLATE   LXV. 


Anteriok  Sueface. 

Left  hydrosalpinx,  with  large  cystic  ovary  and  cysts  of  the  meso-salpinx.     The 
tube  and  ovary  forming  a  mass  with  the  meso-salpinx. 

The  uterine  appendages  of  the  right  side.  The  ostium  (o)  is  closed,  and  the 
tube  is  in  an  early  stage  of  hydro-salpinx,  its  ostial  end  07ily  being  distended 
by  fluid  to  the  size  of  a  pigeon's  egg,  while  its  uterine  portion  is  simply 
thickened.  The  fluid  contains  a  considerable  amount  of  granular  debris, 
which  ajDpears  to  consist  chiefly  of  degenerate  epithelium.  Within  the 
distended  i^ortion  of  the  tube  numerous  plicse  can  be  seen.  Above  it  is 
attached  a  tiny  cyst — jDrobably  a  hydro-salpinx  of  "an  accessory  tube,  while 
below  it,  attached  to  the  broad  ligament  in  the  region  of  the  parovarium, 
are  three  minute  thin-walled  cysts.  Numerous  adhesions  are  present, 
especially  between  the  ovary  and  the  hydro-salpinx.  [_To  face  p.  667. 


AFFECTIONS   OF  THE   FALLOFIAX    TUBES.  067 

sequel  of  a  salpingitis  which  is  arrested  in  the  serous  stage  of  the  in- 
flammation, and  does  not  pass  beyond  it  into  a  pyo-salpinx.  The 
average  size  of  a  liy(ho-sa]pinx  is  about  that  of  a  medium-sized  egg 


Fm.  4.-)7. — HYnnn-sALPixx  Simplex  with  Eight  Cystic  Otauy  attached. 

(AUTHOI!.) 

A  largo  multilocular  cystoma  of  the  left  ovary  was  removed  from  this  case. 
The  tube-wall  was  extremely  thin  and  almost  transparent.  The  contained 
fluid  was  quite  clear  and  limpid. 

or  pear.  It  is  ovoid  in  shape,  and  smooth  ;  its  walls  are  thin  and 
almost  transparent  in  parts.  The  fluid  is  clear  or  pale  yellow  in 
colour. 

Hydro-salpinx  and  hydrometra  have  been  found  to  follow  ligature  of  the 
tubes  and  uterine  cornua,  tube  secretion  passing  from  the  tube  into  the  uterus, 
but  not  into  the  reverse  direction  save  under  some  abnormal  condition. 

Floriep  has  divided  hydro-salpinx  into  two  varieties,  according  as  the 
internal  orifice  of  the  tube  is  closed  or  open.  Tait  attributes  the  cystic 
tendency  in  the  Fallopian  tubes  in  many  cases  to  an  arrest  of  development  of 
tlie  oviduct,  which  is  in  part  obliterated. 


Nature  of  Hydro-salpinx. 

Clement  White,*  from  a  careful  clinical  and  pathological  examination  of 
twenty  specimens  of  Imlro-salpinx,  discusses  the  'retention  cyst'  view  of  its 
causation,  either  from  closure  of  the  ostial  end  and  catarrhal  or  peritoneal 
inflammation,  or  a  secondary  adenomatous  state  due  to  renal  disease.     He 

*  Jour.  Ohstet.  and  Gyn.  Brit.  Emp.,  Fob.,  1904. 


'^X.%.^fhM4&&i^^(TaJi.-isA,c£^  k^^^ 


IK  .C.  S.  ?UA^^«^/^/^.Je^-<^i»I^A 


^\4xMA>t^ 


Fig.  458. — Specimens  op  Accessory  Hydko-salpinx.     (C.  Handley.) 
Photographs  of  three  of  the  specimens  referred  to  in  the  text,  by  Mr.  H.  George,  with  key 


AFFEcrroxs  OF  Tin:  fallopiax  rrnEFf.  <in9 

conios  to  the  coiu'lusiun  that  congenital  closure  of  the  ostia  is  an  inipoitant 
factor  in  its  formation. 

Kelly  divides,  for  clinical  purposes,  hydro-salpinx  into  hydrosalpinx 
simplex,  hi/drops  ttihiv.  p>ro linens,  hydro-saljyinxfoUicuJaris,  and  iuho -ovarian 
cyst.  In  hydro-salpinx  simplex  tlie  tube,  transparent  and  thin-walled,  may 
liold  fluid  in  varying  ([uantities  to  the  extent  of  a  litre.  It  then  somewhat 
resembles  a  parovarian  cyst.  Adhesions  attach  the  ampulla  to  the  ovary  or 
the  pelvic  wall.  The  muscular  wall  is  generally  thinned  out.  The  mucous 
folds  are  branched,  separated  from  each  other,  and  there  are  linger-like  pro- 
jections. The  cilia  may  or  may  not  be  retained.  Kelly  found  a  calculus  in 
one  case  projecting  into  the  lumen  of  the  tube.  In  hydrops  tubae  there  is  an 
outflow  from  the  tube  into  the  uterus  and  vagina,  which  escapes  at  the  vulva. 
The  quantity  of  discharge  varies— sometimes  it  is  considerable  in  quantitj', 
accumulates  in  the  vagina  at  night,  and  is  spontaneously  ejected  on  rising. 
In  follicular  hydro-salpinx  a  section  of  the  tube  shows  the  central  lumen 
surrounded  by  several  small  or  irregularly  shaped  cavities,  separated  by  dis- 
sepiments. The  larger  cavities  are  lined  by  cuboidal  epithelium,  the  smaller 
one  by  cylindrical  cells. 

Accessory  Fallopian  Tubes  and  their  Relation  to  Broad 
Ligament  Cysts. 

Sampson  Handley,*  referring  to  Kossman's  t  view  that  broad 
ligament  cysts  are  neither  parovarian  cysts  nor  cystic  dilatation  of 
the  Wolffian  diyerticula  or  ducts,  but  are  derived  from  accessory 
Mullerian  ducts — sactoparasalpinx  serosa — says  that  this  statement 
is  hardly  supported  by  adequate  evidence,  and  arrives  at  the  con- 
clusion that  cysts  above  the  tube  which  have  a  distinct  cyst  wall 
are  derived  from  the  distension  of  accessory  Fallopian  tubes.  Doran 
has  shown  cysts,  pedunculated  and  other,  quite  free  from  the  par- 
ovarian, developed  above  the  tube,  and  he  anticipated  Kossman  in 
his  view  that  these  possibly  had  a  Mlillerian  origin.  Handley  found, 
in  the  museum  of  the  Royal  College  of  Surgeons,  such  a  l)road 
ligament  cyst  communicating  with  the  Fallopian  tube^J 

Anatomy  of  Hydro-salpinx. — Handley,  noting  the  gradual  thin- 
ning of  the  wall  of  the  hydro-salpinx  from  its  uterine  to  its  ostial 
end,  shows  that  this  attenuation  is  attended  by  corresponding  and 
hyaline  degeneration.  This  latter  proceeds  from  the  almost  normal 
Fallopian  structures  at  the  uterine  end,  with  associated  changes  in 
the  plica  and  epithelium. 

*  Jour.  Obstet.  and  Gyn.,  Xov.,  1903. 

t  Allemangr  Gynxcologie,  Berlin,  1903,  Verlag  v.  August  Hhschwald,  p.  351. 
X  For  the  embryological  relation  of  the  hydatid  of  Morgagni  to  the  Mullerian 
duct  and  the  ovarian  fimbria,  see  Handley's  paper  above  quoted. 


670  DISEASES  OF   WOMEN. 

The  epithelial  changes  consist  in  the  absence  of  columnar  epithe- 
lium, and  the  presence  of  cubical  and  non-ciliated,  until  it  is  quite  lost 
in  the  spaces  between  the  plicae,  the  muscular  structure  gradually 
disappearing,  and  the  plicte  and  the  wall  of  the  hydro-salpinx 
becoming  merely  hyaline  fibrous  tissue.  The  plicse  are  the  most 
persistent  of  the  normal  elements  of  the  tube. 

From  the  careful  examination  with  Shattock  of  four  specimens  in 
the  Royal  College  of  Surgeons,  two  of  Lawson  Tait's,  and  one  of 
AUjan  Doran's,  Handley  comes  to  the  conclusion,  from  the  presence 
of  plicje  in  the  cysts,  the  continuity  of  the  cyst  wall  and  the  tube,  the 
presence  of  an  imperfect  accessory  tube,  and  the  discovery  of  columnar 
epithelium  in  the  cysts,  that  these  cysts  are  accessory  hydro-salpinxs. 
He  says  that  '  until  the  contrary  is  proved,  it  is  a  fair  inference 
that  all  enucleable  cysts  of  the  broad  ligament,  developed  above 
the  tube,  arise  from  the  distension  of  accessory  tubes,  parasitic  cysts 
of  course  excepted.' 

Hamilton  Bell  made  a  minute  examination  of  a  cyst  removed  by 
Cullingworth,  and  found  that  the  pathological  features  described  by 
Handley  were  present,  supporting  the  view  of  the  latter  that  it  was 
an  accessory  Fallopian  cyst. 

I  recently  operated  upon  a  patient  for  retroflexion  of  the  uterus 
by  ventre -suspension.  She  had  had  considerable  pain  in  the  left 
side  for  some  time  previous  to  the  operation,  in  consequence  of 
which  she  was  unable  to  pursue  her  calling  as  governess.  In 
removal  of  the  adnexa,  a  cyst  attached  to  the  broad  ligament 
ruptured.  Seeing  the  accessory  cysts  in  the  free  edge  of  the  broad 
ligament,  I  requested  Dr.  Handley  to  furnish  me  with  a  report  of 
the  specimen. 

'  The  specimen  (Fig.  459)  consists  of  the  left  uterine  appendages,  removed 
by  oophorectomy.*  No  inflammatory  adhesions  are  present.  The  Fallopian 
tube  is  normal,  except  that  it  lacks  the  hydatid  of  Morgagni,  and  that  the 
ovarian  fimbria  is  absent. 

'  Iq  the  free  edge  of  the  broad  ligament,  between  the  ostium  and  the  outer 
pole  of  the  ovary,  are  two  small  cysts,  lying  between  the  peritoneal  layers 
of  the  broad  ligament,  along  the  normal  line  of  the  ovarian  fimbria.  The 
upper  one,  nearly  spherical,  is  10-  mm.  in  diameter ;  the  lower  one,  which 
is  oval,  with  its  long  axis  parallel  Avith  the  edge  of  the  broad  ligament,  is 
12  mm.  long.     The  cysts  contain  clear  watery  fluid. 

'  A  microscopical  examination  of  the  edge  of  the  broad  ligament  between 

*  Since  this  has  been  written  I  have  met  with  two  other  well-marked  instances 
of  accessory  tubes — cysts  lined  with  ciliated  columnar  epithelium,  the  wall  of 
the  cyst  in  one  instance  being  muscular. 


AFFECTIOSS   OF   THE    FALLOPIAN   TUBES. 


G71 


the  cysts  shows  that  it  is  covered  only  1>y  peritoneal  eiidotlieliuni,  witlioiil 
a  trace  of  the  ovarian  timhria. 

'The  lower  cyst  has  a  thin  wall  of  laniinated  fihrous  tissue,  lineil  within  hy 
cubical  epithelium.     It  was  not  ex;iniincd  in  its  wliole  circumference. 

'The  upper  cyst  was  embedded  witliout  opening  it.     Its  thin  wall  consists 


Fig.  4.59. — Left  Uteiune  Appendages  avith  the  Cysts  ix  the  Fkee  Edge 

OF   THE   BltOAD   LiGAMEXT.*      (AUTHOR.) 

of  laminated  fibrous  tissue,  which  may  or  may  not  be  degenerate  muscle. 
It  does  not  give  the  van  Gieson  staining  reaction  for  muscular  tissue.  The 
cyst  is  lined  by  a  single  layer  of  columnar  epithelium,  which  here  and  there 
is  ciliated.     At  one  point  within  the  cyst  are  seen  two  vascular  finger- like 


Fig.  -iOn.— Section  of  Wall  of  Upper  Cyst  saiAnxG  the  Plice.    (C.  HANi>LEy.) 
There  is  a  large  vessel  at  the  base  of  each. 

projections,  with  a  fibrous  core  covered  by  columnar  epithelium  (Fig.  4G0). 
In  an  adjoining  section  these  projections  are  seen  to  have  fused  \>y  their 
tips,  arching  over  a  little  cavity  which  is  completeh^  lined  by  columnar 
epithelium.     (Fig.  461.) 

'  The  structures  just  described  are  identical  with  the  plicae  and  sub-plical 

*  Cysts  of  Miillerian  origin  replacing  the  ovarian  fimbria  at  the  outer  edge  of 
the  mesosalpinx. 


672 


DISEASES  OF   WOMEN. 


spaces  which  I  have  described  as  present  in  cysts  of  the  broad  ligament 
situated  above  the  tube  ;  *  and  familiar  in  ordinary  hydrosalpinx. 

'  The  two  cysts  present  in  this  specimen  are  therefore  derived  either  from 
the  Fallopian  tube,  or  from  diverticula  connected  with  it  (accessory  tubes). 

'  In  the  paper  referred  to,  reasons  are  given  for  believing  that  the  upper  end 
of  the  Miillerian  duct  lies  at  the  ovarian  end  of  the  ovarian  fimbria,  and  that 
the  latter  structure  is  simply  an  opened-out  portion  of  the  MiiUerian  duct. 

'  The  absence  of  the  ovarian  fimbria  in  this  specimen,  andjts  replacement 


Fig.  461. — The  Plic^  fused  at  the  Tips  leaving  Cavity  lixeu  by 
Columnar  Epithelium  fokming  a  Subplical  Space. 

by  two  cysts  whose  walls  have  certain  characters  of  a  distended  Fallopian 
tube,  lends  support  to  the  theory.  Owing  to  an  abnormality  of  development, 
the  uppermost  portion  of  the  Miillerian  duct,  instead  of  dehiscing  to  form 
the  ovarian  fimbria,  has  in  part  become  atresic  and  disappeared.  The  two 
cysts  represent  persistent  portions  of  it. 

'  The  specimen  is  important  as  proving  that  certain  cysts  of  the  outer  edge 
of  the  broad  ligament  are  of  Miillerian  origin.' 

Another  specimen,  a  drawing  of  which  is  shown  (Fig.  462),  was 
examined  for  me  by  Dr.  Handley,  and  he  reported  on  it  as  follows  : — 

'  The  specimen  consists  of  the  right  uterine  appendages,  removed  by  oopho- 
rectomy. Only  the  outer  portion  of  the  Fallopian  tube,  4  mm.  in  length,  is 
present.     The  ostium  is  very  small,  though  patent. 

'  The  ovarian  fimbria  is  absent,  and  its  place  is  taken  by  a  cj'st  15  mm.  in 
diameter  lying  in  the  free  edge  of  the  broad  ligament.  Attached  to  the 
external  convexity  of  this  cyst  from  above  downwards  are  three  appendages — 
(a),  a  stalked  cyst  10  mm.  in  diameter ;  (V),  a  tiny  tuft  of  fimbree  3  mm.  long  ; 
(c),  a  small  stalked  cyst  5  mm.  in  diameter. 

'  Two  sharp  folds  of  peritoneum,  separated  by  a  sulcus,  run  from  the  ostium 
to  the  base  of  attachment  of  the  large  cj'st,  on  its  anterior  and  posterior 
aspects  respectively.     Hanging  from  the  anterior  fold  is  a  cyst  about  4  mm. 

*  '  On  the  Origin  from  Accessory  Fallopian  Tubes  of  Cysts  of  the  Broad 
Ligament  situated  above  the  Fallopian  Tube,'  Jour.  Ohstet.  and  Gyn.  of  Brit. 
Emp.,  Nov.,  1903. 


AFFECTIONS  OF  THE   FALLOPIAN   TUBES. 


673 


in  diameter,  and  from  the  posterior  one  a  bluntly  cylindrical  appendage  5  mm. 
long  by  4  mm.  broad,  which  appears  to  iiave  the  characters  of  an  accessory 
Fallopian  tube. 

In  this  specimen  the  ovarian 
fimbria,  which,  as  I  have  else- 
where shown,  represents  the 
opened  out  uppermost  part  of  the 
jMiillerian  dnct,  is  replaced  by 
the  large  cyst  in  the  free  border 
of  the  broad  ligament.  This  cyst 
should  therefore  show  the  pe- 
culiarities of  hydro-salpins,  and 
indeed  perfectly  characteristic 
plicffi  can  be  seen  within  it  by 
tlie  naked  eye  when  the  speci- 
men is  held  up  to  the  light. 

It  seems  probable,  from  the 
situation  of  the  smaller  cj'sts 
and  appendages  in  or  near  the 
outer  edge  of  the  broad  liga- 
ment, that  the  parovarian  took 
no  share  in  their  formation,  and 
that  they  represent  in  abnormal 
number  the  pronephric  funnels  * 
from  which  the  uppermost  part 
of  the  ^liillerian  duct,  certainly  in  the  chick  and  probably  in  man,  takes  its 


Fig.  4G2.  —  Cystic  axd  sclerosed  Ovary 
WITH  Accessory  Tube- Cysts  axd  Hyuro- 
SALi'ixx.     (Author.) 


Hsemato-salpinx. 

As  in  the  instance  of  the  serous  cystic  distension,  so  ha?mato- 
salpinx  is  to  be  regarded  as  a  true  cystic  distension  of  the  Fallopian 
tube  with  blood.  It  is  not  a  mere  transitory  effusion  which  escapes 
or  is  absorbed,  and  it  should,  strictly  speaking,  be  kept  quite  distinct 
from  the  blood  which  escajjes  in  a  ruptured  tubal  pregnancy,  though 
some  authors  still  apply  this  term  to  the  latter.  Nor  is  the  possible 
detention  of  blood  in  the  tube  (the  consequence  of  a  congenital 
atresia  of  the  vagina  or  uterus)  to  be  confounded  with  true  htemato- 
salpinx. 

Tubal  Apoplexy  and  Hsemato-cystic  Hsemorrhage. — Pozzi  divides 
hfemato-salpinx  into  two  principal  forms,  according  to  their  etiology. 
The  first  he  attributes  to  an  apoplexy  of  the  tube,  following  upon 
catarrhal  congestion,  or  on  menstrual  suppression  and  irregularities. 
These  are  those  more  temporary  sw^ellings  which  occur  in  previously 

*  Quain's  '  Anatomy,'  vob  1.,  part  i.,  p.  122. 

2  X 


674 


DISEASES   OF   WOMEN. 


thickened  and  altered  tubes.  They  are  generally  reabsorbed  after 
a  short  time,  leaving  the  tube  in  its  original  changed  condition. 
The  sanguineous  effusion  may  occur  from  the  mucous  lining  of  the 
tube.  This  was  many  times  insisted  on  by  Tait,  Thus,  the  tube, 
when  fixed  in  the  pedicle  in  the  abdominal  wall  after  ovariotomy, 
has   been  seen   to  bleed   during  the  time  of    a   menstrual  period. 


In  CI 


ieiied  llooJ^  portion 
of  cyst         ...-••' 
on  [jelv.  rioui'.   ■■. 


Twisted  pedici 


Ftr.  463.— Lkft  Ovakian  Cyst  with  Twisted  Pedicle — including  the 
TtiBO-OvAKiAN  and  Eound  Ligaments.    (Howakd  Kelly.) 


Pressure  from  uterine  myomata  or  intra-ligamentaiy  tumours  may 
also  cause  bleeding  into  the  tubal  cavity,  and  this  may  assume  the 
cystic  form.  HsBmato-cystic  haemorrhage  is  characterized  by  the 
presence  of  a  sac.  This  sac  Pozzi  looks  on  as  a  tubal  pregnancy 
arrested  in  its  development,  and  followed  by  the  death  of  the  embryo, 
which  is  reabsorbed  ;  or  it  may  be  that  there  has  been  a  pyo-salpinx 
which  has  obliterated  the  outer  orifice  of   the   tube,   and  in  this 


AFFKCTIOXS   OF   THE   FAf./.OPIAX    TUBES.  'un 

pathological  cavity,  incapable  of  reabsorption,  the  blood  is  efiused. 
At  times,  he  says,  this  transition  may  be  direct  from  a  pyo-salpinx 
to  a  haemato-salpinx,  or  there  may  be  an,  intermediate  stage  in  which, 
after  hydro-salpinx,  the  sanguineous  effusion  occurs.  The  sac  may 
vary  in  thickness  in  different  parts,  and  the  fluid  differs  in  con- 
sistence, dependent  upon  the  cause  of  the  effusion.  The  mucous 
lining  is  generally  thickened,  and  its  surface  in  parts  is  crowded 
with  engorged  capillaries,  the  fusiform  cells  covering  which  are 
devoid  of  epithelium. 

Twisted  Fallopian  Tube  and  Infarcted  Hydatid. 

An  interesting  case  *  of  hsemon-hagic  infarction  of  the  Fallopian  tube  due 
to  (1)  a  CN-stic  formation  in  the  tube,  (2)  distortion  from  adhesions  and 
rotation  of  the  pedicle  of  the  cyst,  is  recorded  by  W.  W.  Kussell.  Cceliotomy 
was  performed  by  Howard  Kelly,  after  a  succession  of  attacks  of  abdominal 
pain  and  vomiting.     At  both  sides  the  ovaries  were  adherent  to  the  pehnc 


Fig.  464. — Imaic.tll.  Hydatid  to  Eight,  with  Constricted  Pedicle  at  its 
Left  Extkejiitt.  Ixfarcted  Fallopiax  Tube  above  to  Left;  Ovary, 
with  Xorjial  Uterine  End  of  Tube  overlying  it,  to  Left  below  this. 

The  drawing  three-fourths  natural  size.    (Howard  Kelly.) 

wall.  The  right  Fallopian  tube  was  turned  upon  itself,  so  that  the  ampulla 
rested  against  the  posterior  side  of  the  isthmus  and  meso-salpinx,  the  tube 
being  patent  except  at  the  fimbriated  extremity.  A  process  of  necrosis  had 
set  in,  rendering  the  tissue  soft,  friable,  and  of  a  dark-red  colour.  A  pedun- 
culated mass,  two  centimetres  in  length  and  five  millimetres  in  diameter, 
sprang  from  the  buried  fimbriated  end  of  the  tube,  its  pedicle  being  twisted 

*  Amer.  Jour,  of  Obstet.,  vol.  xxx.,  1894. 


676 


DISEASES   OF   WOMEN. 


from  left  to  right.  The  mass  measured  6  x  6  x  4|  centimetres,  and  its  sur- 
face was  of  a  smooth  and  hrownish-red  colour.  It  contained  clear  serous 
fluid,  its  walls  being  two  millimetres  in  thickness.  The  microscopical 
examination  proved  that  there  had  been  haemorrhage  into  the  tissues. 

Pyo-salpinx — Causation.  —  The  purulent  collection  may  follow 
catarrhal  salpingitis,  and  is  generally  found  at  the  outer  end  of 
the  tube.  The  character  of  the  fluid  varies  considerably.  It  is 
generally  crowded  with  epithelial  cells.  The  more  frequent  causes 
of  purulent  inflammation  of  the  tube  are  septic  conditions  started 
by  uterine  operations,  the  use  of  the  sound,  gonorrhoea,  and  those 
other  septic  states  which  follow  on  abortion  and  miscarriage. 
Attempts  at  criminal  abortion  by  rude  hands  frequently  cause  these 
suppurating  affections  of  the  tubes  and  ovaries. 

Pathological  Changes. — The  outer  extremity  of  the  tube  may 
be  closely  adherent  to  an  ovary,  and  this  is  the  more  usual  condition. 

Adhesions  may 
attach  the  tube 
and  ovary  to  the 
peritoneum  in 
Douglas'  pouch,  or 
to  the  rectum  or 
uterus.  The  ap- 
pendages on  both 
sides  are  generally 
involved,  especi- 
ally in  gonorrhoeal 
salpingitis.  This 
is  an  important 
clinical  fact  to  re- 
member in  the 
treatment  of  pyo- 
salpinx.  The 
thickness  of  the 
suppurating  cyst-wall  varies.     Such  a  suppurating  cavity,  contracting 

*  This  section  was  made  and  stained  by  Ludwig  Pick,  in  my  presence,  within 
12  minutes  of  its  removal  by  Professor  Landau.  He  uses  Jung's  Hobel 
microtome  (Leitz,  Dorotheen  Strasse,  Berlin).  Sections  having  been  made  are 
transferred  to  4  per  cent,  formalin  solution  for  ?>  to  .4  minutes.  Nest  they  are 
transferred  to  4  per  cent,  of  carmine  and  5  per  cent,  of  alum.  They  are  then 
placed  in  water  for  a  few  seconds,  and  then  in  alcohol,  80  per  cent.,  for  10 
seconds;  after  this  in  absolute  alcohol  for  a  few  seconds,  and  finally  in 
carbolised  xylol  (one  xylol  to  three  of  carbolic  acid). 


Fig.  465.- 


-Section  .  OF  Fallopian  Tube  *  eemoved 
FOR  Pyo-salpinx. 


X 


< 


V- 


H. 


^^W; 


—       3^       H 


a   =   H  ^-' 


>    C    = 

Cos 


X    ^  .2 

■A    ^t^ 


-^I      c    ^    S 


>    =    5 


J.  ~   -    p 


AFFECTIONS   OF  THE  FALLOPIAN   TUBES.  ^Til 

adhesions  with  the  rectum  or  bladder,  may  burst  into  either.  The 
pus  is  generally  thick  and  creamy,,  and  fcrtid  if  the  cavity  be 
close  to  the  rectum.  The  contiguity  of  the  sac  to  the  ovary  leads 
generally  to  the  involvement  of  the  latter,  which  in  its  turn  becomes 
purulent,  though  the  suppurating  process  may  have  begun  in  the 
ovary.  This  involvement  of  the  broad  ligament  and  ovary  is  more 
likely  to  occur  by  a  spreading  of  the  suppurative  process  if  there  be 
a  pre-existing  cystic  condition  of  either  of  these.  The  wall  of  the 
pyogenic  cavity  is  greatly  thickened,  and  has  in  an  exaggerated 
form  all  the  pathological  characteristics  of  catarrhal  salpingitis  of 
the  chronic  type  (infiltration  of  embryonic  and  fusiform  cells),  while 
near  the  surface  of  the  mucous  lining  the  cell-growth  is  so  abundant 
as  to  have  the  appearance  of  granulation  tissue. 

The  patient  from  whom  I  removed  the  adnexa  shown  in  Plate  LXVI.  was 
suffering  from  an  over-distended  bladder  and  partial  incontinence.  At  her 
first  ^-isit  five  pints  of  urine  were  drawn  off.  At  that  examination,  and  subse- 
quently during  an?esthesia,  a  hard  mass  was  found  filling  the  pelvic  brim  and 
pushing  the  uterus  upwards  out  of  the  pelvis.  The  retention  had  been  brought 
about  by  unavoidable  over-distension  of  the  bladder  some  three  weeks 
previously  to  my  seeing  her.  8he  had  never  at  any  time  hefore  complained 
of  j)elvic  symptoms,  nor  had  she  suffered  pain.  There  had  been  frequent 
recurrent  malarial  attacks,  first  contracted  in  the  tropics.  During  the  first 
week  she  was  under  observation  she  passed  daily  from  six  to  seven  pints  of 
limpid  urine,  sp.  gi-.  1010,  and  there  was  a  shght  deposit  composed  entirely 
of  pus.  There  were  some  hyahne  casts  present ;  oophoro-salpingo-hysterec- 
tomy  was  performed.  The  sound  passed  into  the  bladder  before  operation 
reached  to  ivithin  two  inches  of  the  umbilicus.  The  operation  was  extremely 
difiScult,  owing  to  the  mass  of  adhesions  at  either  side  and  the  size  of  the  pus 
sacs,  the  right  one  being  larger  than  a  cricket-ball,  and  the  left  than  a  goose's 
egg.  The  tubes  also  were  enormously  thickened.  There  was  an  enlarged 
right  kidney.  The  iliac  vessels  were  bared  by  the  stripping  off  of  the  capsule 
for  some  distance  at  the  left  side.  The  uterus  was  removed  with  the  adnexa 
by  the  supra- vaginal  operation.  Drainage  was  made  through  the  abdominal 
wound  from  the  pouch  of  Douglas.  An  opening  was  subsequently  made  into 
the  pouch  of  Douglas,  and  pus  evacuated.  As  the  temperature  still  remained 
high  an  abdominal  exploration  was  made  a  month  later — nothing  was 
discovered.     Tliis  patient,  seven  years  after  operation,  was  in  perfect  health. 

Marj'  Dixon-Jones,  in  speaking  of  the  complete  anatomical  and  physiological 
destruction  of  the  tubal  walls,  mucosal  and  muscular,*  says  :  '  If  we  can 
imagine  such  inflamed  and  suppurating  tubes  "  cured,"  it  can  only  be  that  the 
diseased  structure  is  replaced  by  fibrous  connective  tissue  ;  and  fibrous  con- 
nective tissue  cannot  perform  the  functions  of  muscle  fibres.  Besides,  this 
newly  formed  fibrous  tissue  frequently  seems  to  have  a  tendency  to  take  on 

*  Communication  to  author. 


678  DISEASES   OF    WOMEX. 


new  inflammation,  or  break  down  into  an  inflammatory  corpuscle,  foflowed 
bj'  suppuration. 

'  In  a  bad  case  of  pj'o -interstitial  salpingitis,  tbe  Fallopian  tubes  can  never 
after  be  made  to  perform  their  normal  functions ;  they  are  only  a  source  of 
disease  and  infection  for  the  whole  system.' 

Symptomatology. — Pyo-salpinx  occasionally  does  not  manifest 
itself  by  the  presence  of  any  marked  pyogenetic  symptoms.  On  the 
other  hand,  pain  may  be  intense,  there  may  be  gi'eat  bladder  distress, 
pain  in  urination,  and  all  the  attendant  symptoms  of  perimetritis, 
such  as  rigors,  hyperpyrexia,  and  intense  abdominal  tenderness  with 
tympanites. 

In  the  case  of  gonorrhoea,  there  may  be  associated  local  signs, 
in  the  vulva,  urethra,  and  vagina,  of  the  gonorrhoeal  infection. 
Difficult  and  painful  deftecation  may  be  the  consequence  of  an 
accumulation  in  the  pouch  of  Douglas,  which  presses  on  the 
rectum,  and  involves  the  peritoneal  reflexion.  The  fear  of  pain 
will  then  deter  the  woman  from  permitting  the  movement  of  the 
bowel.  Reviewing  all  the  symptoms  of  the  gonorrhoeal  attack, 
we  are  assisted  in  arriving  at  a  conclusion  as  to  the  cause  by  the 
mode  of  onset  of  the  inflammation,  the  more  localized  character 
of  the  pain,  the  history  and  proofs  of  a  recent  gonorrhoea,  the 
presence  of  the  gonococcus  in  the  secretions,  and  the  absence  of 
those  signs  which  are  generally  characteristic  of  septicemic  peri- 
tonitis. Taken  altogether,  the  attack  of  sepsis  is  more  acute, 
virulent,  and  painful,  and  the  constitutional  symptoms  are  far  more 
pronounced.* 

Pus  may  collect  in  one  or  both  of  the  Fallopian  tubes,  and  be 
encapsuled  in  them,  or  it  may  be  found  in  an  abscess  cavity  common 
to  both  the  tube  and  ovary.  It  may  also  collect  around  the  vermi- 
form appendix,  and  find  its  way  into  the  adjacent  tubes.  In  the 
purulent  collections  are  found  either  the  gonococci,  the  streptococci, 
or  the  staphylococcus — the  latter  being  comparatively  rare ;  and  still 
more  rarely  are  the  mixed  infections  due  to  the  presence  of  different 
micro-organisms.  The  contiguity  of  the  left  tube  to  the  rectum  is 
not  to  be  forgotten,  and  the  possibility  of  infective  bacteria  travelling 
from  the  latter  to  the  former ;  this  more  especially  if  there  be 
adhesions  between  the  rectum  and  the  adnexa,  or  an  abscess  between 
the  tube  and  rectum. 

The  important  practical  bearing  of  our  knowledge  of  the  causa- 
tion and  course  of  a  pyo-salpinx  is  to  enforce  these  lessons  :   (a) 

*  See  13.  657,  Gonorrhoeal  Salpingitis. 


I'LATK    L.WIII 


Caecinojia  of  the  Fallopian  Tube. 

«,"«,  solid  portion  of  tumour  ;  h,  tube;  c,  capsular  portion. 

This  specimen  I  found  recently  in  my  private  collection  and  cannot  trace  the 
clinical  particulars  of  the  case. 

The  tumour  is  oval  in  shape,  and  measures  10  inches  in  its  greatest,  and  8 
inches  in  its  shortest,  circumference.  It  has  a  lobulated  surface ;  some  of 
the  lobes  are  smooth,  the  growth  being  enclosed  in  a  tightly  stretched 
fibrous-looking  shiny  cajisule.  Other  lobes  are  rough  and  papilliform, 
consisting  of  growth  which  has  burst  through  the  containing  capsule.  The 
smooth  thin  capsule  has  been  peeled  oif  the  greater  part  of  one  portion  of 
the  growth,  revealing  a  rough  surface  studded  with  nodules  the  size  of  a 
pin's  head.  A  furtlier  portion  of  the  tumour  has  been  cut  tlirough  its 
greatest  diameter ;  the  cut  surface  has  a  pale  yellow  colour,  and  consists  of 
soft  friable  granular-looking  material.  At  one  point  there  was  a  small 
projection  which  admitted  a  fine  bristle.  This  on  transverse  section  proved 
to  be  the  cut  end  of  the  Fallopian  tube.  On  following  this  up,  it  was  found 
to  lead  through  the  capsule  into  the  cavitj'  containing  the  new  growth  (b). 

Microscopical  Eeport  (Cuthbert  Lockyer). — Sections  have  been  prepared  at 
various  levels  to  show  that  the  capsule  of  the  growth  is  continuous  with 
the  wall  of  the  undilated  tube.  These  sections  prove  that  the  smooth 
capsule  enclosing  the  tumour  consists  of  fibro-muscular  tissue  continuous 
with  that  forming  the  wall  of  the  unexpanded  tube.  The  tumour  is.  in 
fact,  of  tubal  origin. 

Section  I.  showed  a  thickened  tube-wall  with  intact  lumen,  and  with  swollen,  but 
perfect,  plicte.  The  vessels  are  thickened,  and  contain  thrombi.  The  main 
Ij'mphatics  are  injected  by  leucocytes,  but  contain  no  deposit  of  new  growth. 

Section  II.,  taken  a  little  further  on,  showed  a  portion  of  tube-wall  with  car- 
cinomatous growth  arising  from  and  distorting  the  still  existent  plictB. 

Section  III.  showed  a  few  plicte,  but  the  majority  have  disappeared,  giving 
place  to  columns  of  cancer  cells  densely  packed  together,  and  which  have 
lost  their  columnar  shape  and  have  become  more  or  less  spheroidal.  These 
lie  in  close  apposition  to  the  stretched  wall  of  the  tube  :  the  latter  is  here 
invaded  by  cancer  cells,  which  occupy  alveolar  spaces  (lymphatics)  between 
the  fibro-muscular  layers. 

Section  lY.,  taken  fuithest  from  the  non-dilated  end  of  the  tube,  shows  a  much 

thinued-out  tubal  wall,  forming  the  capsule  to  a  dense  solid  carcinomatous 

growth,  composed  of  densely  j^acked  spheroidal  cells,  arranged   in    long 

columns  and  concrete  masses.     ((J.  Lockyer.)  [To  face  p.  <i78. 

(-See  over  jjage.) 


PLATE   LXIX. 


Capsule. 


__  _        Detached 
capsule. 


Gakcinoma  of  the  F.^LLOPIA^•  Tube-Tumoue  laid  open 


[To  face  p.  679. 


AFFECTIONS  OF  THE  FALLOPIAN   TUBES.  679 

pyo-salpinx  is  often  the  sequel  of  a  hydrosalpinx,  and  remains  as  a 
consequence  of  salpingitis  arising  from  any  cause, — its  presence  is  not 
necessarily  associated  with  pain  or  acute  pelvic  symptoms;  (h)  it 
is  frequently  found  in  both  tubes;  (c)  it  often  involves  the  ovary 
in  a  tubo-ovarian  abscess ;  (d)  it  may  become  attached  by  adhesions 
to  the  uterus,  or  the  rectum,  or  possibly  involve  the  bladder  and 
open  into  any  of  these  viscera ;  (e)  the  suppuration  may  be  of  a  tuber- 
culous nature;  (/)  latent  gonorrhoeal  infection  is  a  not  infrequent 
cause,  though  the  pns  formed  in  the  tubes  may  not  contain  the  gono- 
coccus ;  (g)  the  pui<  in  a  pyo-salfinv  is  frequently  sterile.  Remem- 
bering the  tubercular  nature  of  the  infection  in  some  cases  we  must 
be  careful  to  inquire  into  the  family  history  for  any  corroborative 
evidence  in  predisposition  to  tubercle,  and  the  presence  of  the  disease 
in  other  organs,  bearing  in  mind  that  tuberculosis  is  probably  found 
at  the  same  time  in  the  uterus  and  ovary.* 

Primary  Carcinoma  of  the  Fallopian  Tube. — Primary  carcinoma 
of  the  Fallopian  tube  is  a  rare  disease.  It  occurs  near  the  menopause, 
and   is  accompanied   by   vaginal  discharge,  generally    sanious.     Its 


'^~       a 


Fig.  -ifJO. — PiujiAKY  Cakcixuma  op  Fallupian  Tube.     (Hubeiit  Kobekts.) 

a,  fimbriated  extremity ;  h,  ovary  ;  e,  mass  of  carcinoma  invading  wall  of  tube ; 
d,  uterine  end  of  tube;  e,  limit  of  noNv  growth  towards  uterine  end  of  tube; 
/,  masses  of  new  growth  filling  and  distending  the  tube.f 

course  is  apparently  slower  than  that  of  cancer  in  most  other  organs, 
certainly  far  less  rapid  than  in  ovarian  cancer.  Evidence  as  to  the 
origin  and  precise  nature  of  sarcoma  of  the  Fallopian  tube  is  as  yet 
very  scanty. 

Carcinoma  of  the  Tube. — Up  to  1902  Graefe  of  Halle  had  found  fiftj'-two 

*  See  chapter  on  Tuberculosis.  t  Ohsiet.  Soc.  Trans.,  vol.  xl. 


680 


DISEASES   OF    WOMEN. 


recorded  cases  of  primary  carcinoma  of  the  Fallopian  tube.*  Krause  had 
found  gonococci  in  all  the  layers  of  a  tube  wall — in  fact,  in  all  the  structures, 
the  epithelium,  stroma,  muscular  layers,  and  the  sub-serous  tissue  of  the  wall. 

Papilloma. t — Papilloma  of  the  Fallopian  tube  appears  to  have  an 
inflammatory  origin.  It  may  proceed  till  large  masses  of  papillomata 
develop,  these  growths  being  perfectly  innocent,  although  they  may 
even  provoke  ascites  and  hydrothorax.  On  the  other  hand,  the 
papillomatous  vegetations  may  undergo  malignant  degeneration. 

Papilloma  of  the  Fallopian  tube  is  very  uncommon.  Rokitanski  and 
Hennig  described  outgrowths  from  the  papillae  seen  on  the  mucous 
membranes  of  diseased  Fallopian  tubes,  the  latter  authority  noticing 
certain  transitional  stages  of  growth — warty,  papillary,  and  poly- 
poid^which  are  often  seen  side  by  side  in  dropsical  tubes  (Doran). 

Alban  Doran  exhibited  a  large  papilloma  of  the  Fallopian  tube  presenting 
such  papillary  outgrowths  at  the  Pathological  Society  of  London.J  In  this 
particular  case  ascites  and  pleuritic  effusion  were  associated  with  the 
papilloma.  Cauliflower  excrescences  grew  from  various  parts  of  the  mucous 
membrane  of  the  dilated  tube.  Amidst  these  here  and  there  were  cysts  with 
papillary  outgrowths. 


Fig.  467.— Peimaky  Papilloma  of  Fallopian  Tdbe.      (Hubert  Koberts.) 
Eoberts's  second  case.      (J  nat.    size.)     a,  uterine  end  of  tube ;  h,  fimbriated 
extremity ;   c,  c,  mass  of  papillomatous  growth  undergoing  degeneration  ; 
d,  d,  solid  portions  of  growth  involving  wall  of  tube ;  e,  remains  of  meso-sal- 
pinx  thickened. 

Hubert  Koberts  has  published  two  cases  of  primary  papilloma  of  the  Fallo- 
pian tubes.  In  the  first  there  were  repeated  discharges  of  sanious  fluid  per 
vaginam,  preceded  by  pain,  and  there  was  also  more  or  less  a  continuous 


*  Centralb.f.  Gyn.,  1902,  No.  51.  t  See  Papilloma  of  the  Ovary. 

X  Trans.,  1890. 


AFFECTIONS   OF    TUT.    FALLOPIAX    TUIiES.  (-.81 


watery  discharge,  a  leakage  from  the  tube.  The  growth  was  of  a  papillo- 
matous nature,  and  entirely  filled  and  distended  the  lumen  of  the  tube,  save 
within  one  inch  of  its  uterine  ostium,  which  was  patent  and  healthy.  The 
fimbriated  end  was  closed.  lu  the  second  case  the  tumour,  also  of  a 
papillomatous  nature,  was  removed  by  Meredith.  At  its  junction  with  the 
uterus  the  tube  was  healthy.  There  were  no  secondary  deposits  in  the 
peritoneum.     In  both  cases  recovery  was  complete. 

In  this  second  case  (Fig.  467),  there  was  the  condition  of  hydrops  tubfc 
present,  and  the  patient's  attention  was  first  directed  to  curious  cherry- 
coloured  watery  discharges  from  the  vagina,  the  result,  apparently,  of  closure 
of  the  abdominal  ostium,  the  accompanying  distension  of  the  tube  being 
associated  with  great  pain.  The  disease  recurred  within  eight  months  of  the 
operation,  and  death  resulted  within  thirteen  months. 

'  The  sections  show  a  very  advanced  papillomatous  condition  which  springs 
from  the  wall  of  the  tube.  The  normal  plicae  are  very  much  exaggerated 
and  their  contour  lost ;    the  epithelium  consists  of  large  columnar  colls  of 

"■» 
\ 


L»';  *,"..-•>*, 


r  .-^ 


^^.  •:.  :i 


.9 


>. 


h. 


Fig.  408. — Phlmaky  CAKcixoM-i  of  Fallopiax  Tube.*    (Hubeut  Eoberts.) 

irregular  shape,  and  the  deeper  layers  and  walls  of  the  tube  are  involved  by 
similar  irregular  clusters  of  carcinomatous  cells  gathered  in  irregular  lacunae 

*  Obstet.  Soc.  Trans.,  vol.  xl. 


682 


DISEASES   OF    WOMEN. 


and  spreading  into  the  connective  tissue  beneath ;  there  are  degenerative 
changes  in  the  superficial  portions  of  the  growth. 

'The  involvement  of  the  deeper  portions  of  the  tissues  by  the  carcino- 
matous cells  is  eveiywhere  evident. 

Primary  Carcinoma. — Twenty-six  cases  of  primary  carcinoma  of  the  Fallopian 
tube,  collected  by  Doran,*  were  thus  distributed  as  to  age  :  From  55  to  60  years 
inclusive,  seven  ;  50  to  55,  three ;  45  to  50,  twelve ;  40  to  45,  three  ;  35  to  40, 
one ;  total,  26.  The  right  tube  was  affected  in  eleven  cases,  the  left  in  four, 
both  in  nine,  unrecorded  in  two.  Eight  women  of  those  affected  were  sterile, 
seven  had  had  one  child,  two  had  aborted,  three  were  multipara.  There  was 
present  in  nine  a  sanious  and  serous,  or  watery,  discharge.  In  two  cases  the 
discharge  was  described  as  'yellow,'  in  one  it  was  metrorrhagic,  in  two 
hsemorrhagic,  in  one  it  was  purulent  and  acrid.  Looking  to  the  nature  of 
the  malignant  disease,  we  find  in  fifteen  cases  the  character  of  the  tumour 
was  distinctly  papillomatous  cancer,  in  three  it  was  medullary,  in  one  villous 
epithehoma,  in  another  cylindrico-epithelial  villous  carcinoma.  The  precise 
character  of  the  cancer  is  not  stated  in  the  other  cases.  Either  the  uterus, 
peritoneum,  or  intestines  are  noted  as  being  involved  in  seven  of  the  cases  ; 
the  pelvic,  lumbar,  or  inguinal  glands  were  involved  in  three ;  the  ovary  as 
well  as  the  tube  was  invaded  by  the  cancer  in  three  cases.  The  results  of 
operation  as  revealed  by  these  cases  are  not  encouraging,  recurrence  taking 
place  in  the  great  majority,  the  longest  period  being  one  in  which  the  patient 
is  said  to  have  been  '  alive  and  free  from  recurrence  one  year  and  seven 
months  after  operation.'  There  can  be  no  doubt,  as  Doran  maintains,  that 
for  such  cases,  if  the  diagnosis  can  be  fairly  made  beforehand,  abdominal 
cceliotomy  is  the  best  route,  as  affording  freer  scope  for  examination  of  the 

diseased    parts,    and    enabling 
''^       the  operator  to  deal  more  com- 
pletely with   the   area   of  the 
cancer. 

Tubercular  Salpingitis. 

For  the  description  of  Tu- 
bercle of  the  Tube,  see  chapter 
on  Tubercle  of  the  Female 
Genitalia. 

Salpingocele, — Hernia  of  the 
Fallopian  tube  may  occur  into 
the  inguinal  canal  with  or  with- 
out its  associated  ovary,  though 
the  latter  condition  is  extremely 
rare.  The  case  of  Bilton  Pol- 
lard t  is  an  example  of  hernia 
of  both  ovary  and  portion  of 
the   Fallopian  tube,   the   former    being    strangulated.      The   symptoms   of 


Fig.  469. — Salpingocele.     (After  Segaes.) 


*  Trans.,  1890. 


t  Lancet,  1889,  vol.  ii.  p.  165. 


PLATE    LXIXa. 


Cyst. 


Ostium 
abdominale. 


Lumen  ol 
tube. 


..Ovary. 


Meso-salpinx. 
Hydatid  Cyst  (Echinococcus)  of  the  Fallopiax  Tube.*     (T.   W.  Eden.) 
Measurement  of  cyst,  ik  in.  in  vertical,  by  3  in.  in  the  transverse,  and  2J  in.  in 

the   antero-posterior  diameter.     The  average   thickness  of  the  wall  was 

g  of  an  inch.t     See  other  side  for  description  of  cyst. 


*  See  also  pp.  8(30,  951. 

t  Jour.  Obs.  and  Gyn.  Brit.  Emp.,  July,  1904. 
{See  over  page.') 


[To  face  p.  682. 


This  tumour  *  (Plate  LXIXa.)  was  removed,  by  abdominal  cceliotomy,  by  T.  W. 
Eden,  from  a  patient  aged  40.  The  cyst  was  in  the  pouch  of  Douglas,  and 
firmly  adherent  to  the  surrounding  structures.  In  appearance  it  was  not 
unlike  an  ovarian  dermoid  with  cartilaginous  walls.  The  tumour  consisted  of 
the  right  uterine  appendages,  including  a  functionally  active  ovary,  Fallopian 
tube,  and  meso-salpinx.  The  inner  third  of  the  tube  was  not  much  altered 
macroscopically,  while  the  upper  border  of  the  outer  two-thirds  was  closely 
incorporated  with  the  hydatid  cyst.  The  tubal  canal  was  intact,  and  had 
no  communication  with  the  cavity  of  the  cyst,  the  wall  of  the  latter  being 
incorporated  with  that  of  the  tube  by  a  firm  organic  union.  The  ab- 
dominal ostium  was  sealed.  There  was  no  evidence  of  any  hydatiform 
aflfectiou  in  any  other  organ.  The  surface  of  the  cyst  was  roughened  by 
remains  of  adhesions.  Examination  of  the  cyst  proved  it  to  be  a  hydatid 
with  hydatid  vesicles,  containing  large  numbers  of  broad  capsules  and  free 
booklets.  Eden  considers  that  the  origin  of  the  hydatid  cyst  was  due  to 
the  deposition  of  ova  '  in  the  tissues  of  the  upper  wall  of  the  tube,  and  their 
development  in  that  position  was  sufficiently  slow  and  gradual  to  avoid 
rupture  either  into  the  peritoneal  cavity  or  the  tubal  canal.'  Eden  quotes 
Pean's  case  of  hydatid  of  the  ovary,!  and  a  case  of  Doleris  (1896)  of 
hydatid  of  the  Fallopian  tube,  as  the  only  two  iDreviously  recorded  cases 
of  undoubted  primary  hydatid  disease  of  the  ovary  or  Fallopian  tube.  J 

*  See  pp.  861  and  951  for  instances  of  hydatid  cysts  of  the  uterus. 

t  '  Diagnostique  et  Traitment  des  Tumeurs  de  I'Abdomen,'  vol.  iii.  p.  671. 

X  Jour.  Obsfet.  and  Gyn.  Brit.  Emi).,  July,  1904. ' 


AFFECTIONS   OF  THE  FALLOPIAN   TUBES.  68:{ 

strangulation  of  the  tube  or  ovary  are  much  akin  to  those  attending  ordinary 
strangulation  of  the  bowel.  The  treatment  consists  in  an  operation  similar  to 
that  for  hernia — removal  of  the  strangled  ovary  or  tube,  the  return  of  the 
pedicle,  and  excision  of  the  sac. 

Conservative  Operations  on  the  Adnexa. 

The  Ovary. — It  will  be  convenient  here  to  refer  briefly  to  those 
conservative  steps  which  are  resorted  to  whenever  it  is  possible  to 
preserve  either  a  portion  of  ovary  or  to  maintain  the  patency  of  the 
lumen  of  the  Fallopian  tube.  Such  steps  involve  the  most  careful 
inspection  of  the  aflected  adnexa  when  they  are  first  removed  from 
the  abdomen,  or,  should  the  operation  be  that  of  colpotomy,  when 
they  are  drawn  into  the  vagina.  In  the  former  case,  the  affected 
adnexal  mass  is  lifted  well  out  from  the  abdominal  wound,  and 
some  sterilized  gauze  is  so  carried  round  its  base  as  to  protect  com- 
pletely the  abdominal  opening,  and  isolate  the  ovary  and  tube.  This 
enables  us  to  carry  out  any  conservative  step  that  may  be  necessary. 
Should  the  operation  be  vaginal,  the  uterus  is  drawn  down  and  the 
adnexa  with  it,  those  of  each  side  being  examined  separately,  and 
returned  into  the  abdomen  when  the  resection  is  completed.  In  a 
case  where  the  adnexa  cannot  be  withdrawn  from  the  abdomen,  the 
tube  and  ovary  can  be  examined  in  the  Trendelenburg  position, 
and  the  question  of  resection  determined.  In  a  case  in  which 
Olshausen's  or  other  operation  is  performed  for  shortening  the 
round  ligaments,  should  the  adnexa  at  the  same  time  be  found 
aflected,  a  conservative  operation,  if  feasible,  ought  to  be  performed. 
The  whole  question  of  conservative  operations  on  the  adnexa  is 
elsewhere  discussed.*  Obviously,  a  parovarian  cyst  can  be  removed 
without  taking  the  corresponding  tube  and  ovary. 

The  degree  of  cystic  degeneration,  whether  arising  in  the  corpora 
lutea  or  in  the  Graafian  follicles,  that  justifies  the  surgeon  in  sacri- 
ficing the  ovary,  must  be  determined  upon  at  the  time  when  the 
ovary  is  opened  and  inspected.  I  have,  on  different  occasions, 
divided  the  ovary  from  cortex  to  hilum,  resected  small  cysts  and 
punctured  others,  at  times  removing  a  portion  of  the  gland,  and 
then  uniting  the  two  halves,  have  thus  preserved  the  ovary. 

From  our  present  knowledge  of  the  functional  activity  secured 
by  the  transplantation  of  portion  of  an  ovary,  the  importance  of 
conserving  this  is  more  apparent  still. 

Igni-puncture.  —  Treatment    of    the    ovary  by    igni-puncture   was    first 

*  See  chapters  on  the  Ovaries. 


684  DISEASES   OF    WOMEN. 

advocated  by  Polk.  The  small  cyst  is  punctured  with  a  fine  galvano-cautery 
point,  the  larger  ones  are  resected  by  a  V-shaped  incision  after  previous 
enucleation  of  the  cysts. 

Howard  Kelly  is  very  emphatic  on  the  importance  of  not  opening  the 
abdomen  in  cases  of  enlarged  Graafian  follicle  cysts  in  which  a  diagnosis  can 
be  made  that  they  are  simply  distended  cysts  filled  with  serum,  by  vaginal 
or  bimanual  examination,  as  in  this  case  either  spontaneous  rupture  or  the 
pressure  made  by  examination  is  not  followed  by  any  bad  effects.  I  have 
known  this  occur  on  a  few  occasions  myself,  and  have  often,  when  permitting 
a  vaginal  examination  to  be  made  by  another,  had  to  give  the  caution  that 
pressure  must  not  be  used,  or  the  cyst  might  be  ruptured.  On  the  other 
hand,  it  must  be  admitted  that  such  treatment  is  attended  with  the  risk  that 
the  cyst  so  felt  may  contain  other  fluid  than  serum,  and  that  either  blood  or 
pus  may  be  present.  In  either  case  serious  consequences  may  follow.  With 
so  safe  an  operation  as  colpotomy,  it  is  certainly  preferable  in  these  cases, 
for  the  majority  of  surgeons,  to  puncture  the  cyst  by  the  vagina,  or  to  remove 
it  by  colpotomy. 

Practically  the  same  remarks  apply  to  such  conditions  of  the 
ovary  as  hagmatoma,  dermoid  cysts,  or  abscess.  The  method  is 
identical  in  principle  to  that  we  adopt  in  the  case  of  cysts.  The 
healthy  portion  of  ovary  is  retained  when  the  haematoma  is  removed, 
the  pus  cavity  is  opened,  or  first  aspirated  with  a  fine  needle,  the 
wall  scraped,  and  the  wound  in  the  ovary  closed.  All  these  con- 
servative operations  are  easily  performed,  and  perfect  union  is 
effected  by  means  of  a  fine  curved  needle  armed  with  cumol  gut. 
The  only  instruments  required  are  a  needle-holder  (I  prefer 
Olshausen's)  such  as  that  of  Doyen  for  the  peritoneum,  a  small 
Kocher's  forceps,  a  dissecting  forceps,  a  fine  scalpel,  small  curved 
scissors — sharp  and  blunt, — and  a  few  small  curved  needles. 

The  Fallopian  Tube. — To  American  surgeons  is  due  the  credit  of 
having  been  among  the  first  to  advocate  conservative  operations  on 
the  ovaries  and  Fallopian  tubes.  The  names  of  Polk,  Barlow,  and 
Barrows  are  prominent  amongst  American  gynaecologists  who  first 
practised  partial  amputation  and  resection  both  of  the  tubes  and 
ovaries. 

Artificial  Ostium. — Polk  first  made  an  artificial  abdominal  ostium 
in  cases  of  pyo-salpinx,  amputating  the  tube  at  some  distance  from 
the  cornu  of  the  uterus,  washing  it,  slitting  it  up  a  little  way,  and 
uniting  its  serous  and  mucous  coats  by  fine  catgut  ligatures,  and 
bringing  the  new  ostium  thus  formed  into  apposition  with  the  ovary. 
At  the  same  time  the  uterus  is  curetted,  and  tamponed  with  iodo- 
form gauze.  Pus  may  be  imprisoned  in  two  portions  of  the  tube, 
either  at  the  infundibular  end  by  adhesions  with  surrounding  parts, 


AFFECTIONS  OF   THE  FALLOPIAX   TUBES.  085 

or  at  the  uterine  end  by  occlusion  of  the  tube  from  half  an  inch  to 
an  inch  from  the  cornu.  Recognizing  the  fact  that  the  uterus  is 
frequently  a  source  of  salpingitis,  Polk  earnestly  urged  its  thorough 
curettage,  followed  by  evacuation  of  the  recently  efiused  lymph  in  the 
tube  by  opening  the  latter,  washing  it  out  with  sterilized  water,  ap- 
proximating its  inner  and  outer  coats,  and  returning  it  into  the  pelvLs. 

Salpingorrhaphy  consists  of  the  removal  of  the  diseased  portion  of 
the  Fidlopian  tulje  and  the  suture  of  the  healthy  portion  to  the 
uterine  stump. 

Salpingostraphy  (Pozzi)  is  performed  thus  :  A  stylet  is  passed 
down  to  the  uterine  cavity  in  order  to  ascertain  that  the  tube  is 
permeable.  The  ovary  is  now  seized,  and  a  cuneiform  section  of  it 
is  made.  To  the  surface  thus  exposed,  the  tube  is  united  by  a  fine 
catgut  suture.  At  the  same  time,  if  there  be  some  small  cysts  in  the 
ovary,  these  are  either  opened  with  the  knife  or  punctured  with  the 
cautery.  In  the  case  of  removal  of  one  tube,  if  the  other  be  found 
stenosed,  A.  Martin  resects  the  latter,  should  its  condition  justify 
its  retention.  He  also  resects  the  ovary  and  the  diseased  part 
of  the  tube,  forming  a  new  ostium,  and  fixes  it  in  the  manner 
advocated  by  Polk. 

Salpingostomy. — In  simple  hydro-salpinx,  and  in  certain  cases 
of  pyo-salpinx,  a  small  portion  of  the  tube  is  removed,  and  the  parts 
are  brought  together.  The  sutures  take  in  the  muscular  and 
peritoneal  coats.  These  operations  on  the  tubes  and  ovaries  com- 
bined, or  on  the  tubes  alone,  must  be  done  through  the  abdomen, 
if  they  are  to  be  successfully  performed,  but  resection  of  the 
ovaries,  their  igni-puncture  or  simple  puncture,  can  be  efiected  V^y 
anterior  or  posterior  colpotomy. 

'  Skutch,  of  Jena,  devised  the  operation  of  salpingostomy.*  He  operated 
upon  a  sterile  patient,  aged  thirty-eight,  with  moderate  dilatation  of  both 
tubes,  which  is  said  to  have  caused  great  pain,  the  ovaries  and  uterus  being 
apparently  fi-ee  from  disease.  Some  of  the  fluid  contents  of  each  tube  were 
first  withdrawn  by  means  of  a  Pravaz  syringe,  and  found  to  consist  of  clear 
yellow  serum  free  from  pus.  The  ostium  was  then  laid  open,  the  fluid  allowed 
to  escape,  and  an  oval  piece  of  the  wall,  about  one  square  centimetre  in  size, 
cut  away.  Tlie  mucous  membrane  and  serous  coat  were  united  along  the 
margin  of  the  artificial  aperture  by  fine  silk  thread.  Lastly,  a  sound  was 
passed  through  the  aperture  along  the  tubal  canal  into  the  uterus.  Conva- 
lescence was  uninterrupted.  From  the  day  of  the  operation  forward  the 
woman  was  free  from  pain.'     (Doran.) 

*  It  was  first  described  before  the  thurd  meeting  of  the  Deutsche  Gesellschaft 
fur  Gynakologie  at  Freiburg,  in  June,  1889.     See  Centralb.  f.  Gyn.,  Xo.  32,  1889. 


686 


DISEASES   OF    WOMEN. 


Sterilization  of  the  Fallopian  Tubes. — Assuming  a  case  in  which 
we  are  uncertain  of  the  state  of  the  mucous  membrane  of  the  tube, 
and  in  which,  on  gentle  pressure,  from  its  uterine  to  its  abdominal 
end,  some  suspicious  fluid  exudes,  the  lumen  of  the  canal  can  be 
cleansed  out  by  inserting  a  cannula  attached  to  a  syringe,  and 
injecting  a  warm  saline  solution,  which  is  allowed  to  run  out  from 
the  ostium.  This  is  repeated  a  few  times,  and  then  the  tube  is 
finally  washed  out  with  a  weak  formalin  solution,  care  being  taken 
that  the  tube  is  cleansed  and  emptied  before  being  returned  into 
the  abdomen.  The  end  of  the  nozzle  of  the  syringe  or  the  cannula 
should  be  bulbous  and  perforated. 

Adherent  Tubes. — The  separation  of  the  tube  from  the  structures 
to  which  it  is  adherent  has  to  be  gently  conducted.     The  adhesions 


Fig.  iTO. — Adhesions  of  the  Outer  Free  Extremities  of  both  Uterine 

Tubes  to  the  Ovaries.     (Howard  Kelly.) 

The  fimbriated  extremities  of  the  two  tubes  looking  in  opposite  extremities. 

Two-thirds  natural  size. 


are  best  separated  with  the  finger,  aided  by  a  small,  curved,  blunt- 
pointed  scissors.  Thickened  bands  are  divided  with  the  scissors, 
and  longer  bonds  of  union  by  the  scalpel.  Any  slight  bleeding  is 
arrested  by  the  temporary  application  of  a  Zweifel's  forceps,  or, 
should  the  bleeding  interfere,  by  the  application  of  a  fine  gut  liga- 
ture. The  freeing  of  the  tube  may  be  followed  by  the  operation  of 
salpingostomy,  and  a  new  ostium  be  created.  In  this  case  the  mucous 
membrane  must  be  drawn  out  and  sutured  to  the  peritoneal  coat. 

Conclusion. — We  thus  see  that  the  tubes  which  are  affected  by 
simple  hydro-salpinx  can  be  preserved  by  resection  and  adaptation  of 


AFFECTIONS  OF  THE   FALLOPIAN   TI'BES. 


(;87 


the  cut  surfaces  ;  also  that  in  certain  cases  of  pyo-salpinx  the  diseased 
portion  of  the  tube  maybe  removed,  the  liealthy  portion  washed  out, 
and  union  effected  either  with  the  uterine  cornu  or  the  ovary,  and  that 
a  new  ostium  may  thus  be  made  either  at  the  uterine  or  abdominal 
end.  The  same  conservative  step  has  been  taken  by  Olshausen  in  early 
tubal  pregnancy.  Wliat,  then,  are  the  diseased  tubal  states  loliich 
compel  us  to  perform  complete  salpingo-ooplwredomyl  (a)  Cases 
of  hydro-salpinx  in  which  the  disease  has   so  far   extended  as  to 


i 


Fig.  iTl. — Adjiksiuxs  uf  Ovaky,  Tubk.s,  Appendix,  and  C^cum.* 
(HowAKD  Kelly.) 

approach  the  purulent  condition,  in  which  there  is  ulceration  of  the 
mucous  membrane,  or  such  distention  of  the  entire  tube  as  to  render 
any  conservative  operation  futile  ;  {h)  certain  cases  of  hfemato-salpinx 
or  pyo-salpinx  in  which  the  integrity  of  the  tube  cannot  be  regained  : 
(e)  tulies,  suppurative  and  other,  which  are  embedded  or  surrounded 
by  adhesions  ;  (f?)  hiematocystic  tubes  with  thickened  walls,  and  con- 
taining blood  coagula,  or  blood  cysts  ;  (e)  ectopic  tubal  sacs  where  it 
is  not  possible  to  resect  the  tube  ;  (/)  tubercular  and  gonorrhoea! 
abscesses  of  the  tubes — tubercular  pyo-salpinx  ;  (</)  carcinomatous 
and  papillomatous  states  of  the  tubes  ;  (/t)  dermoid  tumours. 
*  Amer.  Med.,  April,  1901. 


CHAPTER    XXXVI. 

EXTRA.-UTERINE    PREGNANCY. 

When  the  fertilized  ovum,  or  oosperm,  becomes  attached,  and  grows 
outside  the  cavity  of  the  uterus,  the  condition  is  termed  extra- 
uterine pregnancy.  Extra-uterine  pregnancy  has  been  found  to  be 
by  no  means  infrequent  by  the  evidence  of  surgical  interference  in 
some  of  its  complications  and  results.  It  is  owing  to  its  clinical 
importance  that  the  subject  has  attained  such  prominence.  By  its 
elucidation  and  the  consequent  improvement  in  surgical  methods 
of  treatment,  numberless  lives  have  been  saved. 

De  Parry,  in  1876,  compiled  a  list  of  five  hundred  cases  of  extra- 
uterine pregnancy,  and,  speaking  of  the  deaths  from  hemorrhage, 
his  words  are  so  striking  that  no  account  of  extra-uterine  pregnancy 
can  be  complete  without  them.     He  says — 

'  A  bleeding  vessel,  through  which  the  red  stream  of  life  is  rushing 
^way,  can  be  ligated.  A  gangrenous  limb,  which  is  destroying  its 
possessor  by  sending  its  poisonous  emanations  to  the  remotest  regions 
of  his  body,  can  be  amputated.  A  cancerous  breast,  which  is  sapping 
the  vitality  of  its  victim  hour  by  hour,  can  be  removed.  .  .  .  An 
aneurism  .  .  .  can  be  cured  by  .  .  .  ligation.  .  .  .  Even  phthisis 
now  counts  its  many  cures.  But  here  is  an  accident  which  may 
happen  to  any  wife  in  the  most  useful  period  of  her  existence,  which 
good  authorities  have  said  is  never  cured ;  and  for  which,  even  in 
this  age,  when  science  and  art  boast  of  such  high  attainments,  no 
remedy,  either  medical  or  surgical,  has  been  tried  with  a  single 
success.  From  the  middle  of  the  eleventh  century,  when  Albucasis 
described  the  first  known  case  of  extra-uterine  pregnancy,  men  have 
doubtless  watched  the  life  ebb  rapidly  from  the  pale  victim  of  this 
accident  as  the  torrent  of  blood  is  poured  into,  the  abdominal  cavity, 
but  have  never  raised  a  hand  to  help  her.  Surely  this  is  an  anomaly, 
and  it  has  no  parallel  in  the  whole  history  of  human  injuries.  The 
fact  seems  incredible,  for  if  one  life  is  saved  by  active  interference. 


EXTHA-UTERINE  PREGNANCT.  G89 


it  may  be  triumphantly  pointed  to  as  the  first  and  only  instance  of 
the  kind  on  record.  In  the  whole  domain  of  surgery — for  we  cannot 
look  to  other  than  surgical  measures  under  the  circumstances — there 
is  now  left  no  field  like  this.  .  .  .  The  only  remedy  that  can  be 
proposed  to  rescue  a  woman  under  these  unfortunate  circumstances 
is  giistrotomy — to  open  the  abdomen,  tie  the  bleeding  vessels,  or  to 
remove  the  sac  entu'e.' 

It  is  necessary  to  regain  something  of  the  old  mental  obscurity  as 
regards  the  conditions  found  in  the  abdomen  when  opened  in  order 
to  grasp  the  impasse  in  which  the  old  surgeons  found  themselves. 
The  surgeon  even  thirty  years  ago,  when  daring  enough  to  open  the 
abdomen  in  a  case  of  extra-uterine  pregnancy  with  bleeding,  found 
himself  face  to  face  with  a  tangled  group  of  bowels,  clots,  adhesions, 
festal  sac  and  foetus,  and  blood  seemingly  coming  from  all  and  every 
organ  or  tissue.  He  tied  numerous  ligatures  on  everything  which 
bled,  and  still  the  red  fluid  welled  forth.  No  wonder,  when  the 
patient  lay  dead  under  his  hands,  that  he  determined  in  future  to 
leave  such  cases  to  nature,  and  his  subsequent  case  being  peihaps 
fortunate,  owing  to  rest  and  absorption,  and  a  more  favourable 
termination  of  the  extra-uterine  gestation,  he  was  still  more  strongly 
settled  in  his  determination. 

By  the  aid  of  the  knowledge  gained  from  careful  and  patient 
investigation,  any  capable  surgeon  can  now  obtain  results  which 
are  amongst  the  highest  achievements  of  surgery. 

The  term  extra-uterine  pregnancy  is  the  most  generally  used, 
but  that  of  ectopic  gestation  is  perhaps  more  accurately  descriptive 
of  the  conditions,  since  the  interstitial  variety  of  pregnancy  is 
scarcely  extra-uterine,  yet  it  is  ectopic.  As  the  great  preponderance 
of  these  pregnancies  or  gestations  begin  and  are  found  in  the  tube, 
the  term  tubal  pregnancy  has  also  been  rather  loosely  used  to  designate 
the  entire  group. 

Etiology. — The  exact  causation  of  extra-uterine  pregnancy  is 
not  known,  but  the  probable  causes  are  now  better  understood 
and  defined.  Diihrssen  has  described  one  case  where  a  tubal 
polypus  was  found  on  the  uterine  side  of  a  tubal  pregnancy.  This 
polypus  acted  as  a  ball  valve,  and  admitted  the  spermatozoa  from 
the  uterus,  but  prevented  the  passage  of  the  oosperm  (fertilized 
ovum)  to  the  uterus.  Diihrssen  has  shown,  by  applying  a  cover- 
glass  to  the  abdominal  ostium  of  the  tube  while  performing  vaginal 
coeliotomy  for  retroflexion  in  married  women,  that  the  spermatozoa 
pass  through  the  tube.     The  proof  of  the  occurrence  of  several  cases 

2  Y 


690  DISEASES    OF   WOMEN. 

of  ovarian  pregnancy  now  places  this  passage  of  the  spermatozoa  up 
the  tube  beyond  doubt. 

The  question  of  the  place  where  the  ovum  and  the  spermatozoa 
meet  is  important, 

Lawson  Tait  held  that  the  uterus  was  the  seat  of  normal  conception, 
and  consequently,  when  conception  (fructification  or  fertilization) 
happens  outside  the  uterus,  the  chances  are  that  the  oosperm  will 
become  attached  outside  the  uterus.  Thus  extra-uterine  pregnancy 
is  due  to  fertilization  in  an  abnormal  situation. 

Bischoff,  His,  and  Strassmann  argue  that  the  union  of  the  ovum 
and  spermatozoa  takes  place  in  the  Fallopian  tube,  probably  at 
the  fimbricated  end,  and  immediately  after  the  exit  of  the  ovum 
from  the  ovary.  Consequently,  according  to  this  theory,  each 
pregnancy  begins  as  an  extra-uterine  one,  and  therefore  an  extra- 
uterine pregnancy  of  clinical  import  is  due  to  retarded  movement 
of  the  fertilized  ovum  and  its  attachment  outside  the  uterus. 
Taylor  inclines  more  to  this  view,  and  points  out  that  in  the  second 
week  the  ovum  is  from  3  to  6  mm.  in  diameter.  He  says,  '  It  is 
evident  that  any  want  of  development  in  the  tube,  any  permanent 
contraction,  any  swelling  of  the  mucous  membrane,  any  abnormal 
length  of  tube,  any  extra  weight  or  impaired  mobility  of  the  ovum 
at  its  entrance  into  the  tube,  any  failure  of  muscular  power,  or  any 
interference  with  the  peristaltic  action  of  the  tube,  may  increase 
the  tendency  towards  a  tubal  instead  of  a  uterine  settling.'  Lawson 
Tait  held  that  desquama^tive  salpingitis  was  the  chief  cause  of  the 
abnormal  settling  of  the  ovum,  and  that  in  most  cases  of  tubal  ges- 
tation there  was  a  history  of  inflammatory  disease  of  the  appendages. 

This  view  finds  much  support  on  the  Continent.  Mandl  and  Von 
Schmidt  found  that,  of  seventy -seven  cases  operated  upon  in  Schauta's 
clinic,  twenty-seven  occurred  in  women  who  had  had  gonorrhoea ; 
and  Shober  has  reported  a  case  of  tubal  gestation  associated  with 
primary  tuberculosis  of  the  tube.  Taylor  has  noticed  the  frequency 
of  an  atrophic  condition  of  the  tube,  especially  in  hyper-involution 
from  superlactation.  Several  cases  of  extra-uterine  pregnancy  have 
been  found  where  myoma  or  other  tumour  obstructed  the  tube. 
Ectopic  gestation  is  very  apt  to  occur  in  women  who  have  been 
sterile  for  some  years. 

It  is  therefore  evident  that  extra-uterine  gestation  is  due  to  the 
arrest,  attachment,  and  development  of  a  fertilized  ovum  (oosperm) 
in  its  passage  from  the  follicle  to  the  uterus.  This  arrest  may  be 
due  to  obstruction  or  want  of  propulsion. 


X! 
XI 

< 

CM 


e3   O 


^  <. 


>     . 
2  i 


■^    -^  — '   2 


PLATE   LXXI. 


Interstitial  Gestatiox  at  the  Fourth  Moxth.     (Bumm.) 

Reduced  i.     A,  cavity  of  the  ovum  ;  B,  placenta  ;  C,  right  tube  ;  D,  ovary  ; 
B,  uterine  canal ;  F,  right  adnesa ;  G,  dilated  cervix. 


PLATE   LXXII. 

'  1 


OvAEiAx  Gestation.*    Eupture  in  the  Sixth  .Week.     (C.  Van  Tussenbroek, 

FROM    BUMM.) 

],  chorion;  2,  cavity  ;  8,  rupture  of  sac  wall;  4,  wall  of  the  sac  formed  from 
an  expansion  of  th«  wall  of  corpus  luteum  ;'  5,  blood  coagula  ;  6,  diverticu- 
lum of  a  corpus  luteum;  7,  opening  of  a  corpus  luteum  blocked  witli 
fibrine;   8,  diverticulum  of  the  luteum  ;  9,  follicles  ;  10,  hilum  of  ovary. 


*  Annals  of  Gynxcology,  1899. 


[To  face  p.  691. 


EXTEA-UTERINE   PREGNANCY.  691 

Andrews  gives  the  following  list  of  conditions  which  may  lead 
to  extra-uterine  pregnancy.* 

1.  Salpingitis  and  perimetritis. 

2.  Persistence  of  infantile  conditions  of  the  tube. 

3.  Polypi,  diverticula,  myomata,  etc.,  in  the  tube. 

4.  Puerperal  atrophy  of  the  tube. 

5.  Atavism,  reversion  to  a  lower  developmental  type  of  tube. 

6.  '  External  wandering '  of  the  ovum. 

7.  '  Internal  wandering'  of  the  ovum. 

8.  Abnormalities  of  the  ovum  itself. 

Classification. — According  to  the  situation  of  the  arrest  and 
attachment  and  growth  of  the  oiisperm,  the  cases  of  extra-uterine 
pregnancy  are  classified  into — 

1.  Ovarian.  This  is  probably  due  to  some  thickening  of  the 
tunica  albuginea,  which  retards  the  rupture  of  the  Graafian  follicle, 
and  renders  the  opening  so  small  that  spermatozoa  enter,  but  the 
ovum  cannot  escape ;  or  to  detention  of  the  escaping  ovum  by 
adhesions. 

2.  Abdominal.  Primary  abdominal  pregnancy  has  not  been  proved 
to  exist,  and  it  is  the  tubo-abdominal  or  utero-abdominal  (abdominal 
or  ventral)  pregnancy  which  is  loosely  termed  abdominal. 

3.  Tubal. 

4.  Tubo-uterine.  This  is  arrest  within  the  uterine  portion  of  the 
tube,  with  secondary  invasion  of  the  uterus.  It  must  be  regarded 
as  a  subdivision  of  Tubal  Pregnancy. 

Ovarian  Pregnancy. — This  was  a  much-disputed  and  denied  form 
of  extra-uterine  pregnancy  until  absolute  proof  had  been  brought 
forward  of  its  occurrence.  In  certain  cases  of  iutra-ligamentary 
situation  of  the  ovum  and  of  encapsulated  haematocele  about  the 
ovum,  the  ovary  forms  part  of  the  outer  wall  of  the  sac  containing 
the  pregnancy ;  and  these  were  the  cases  usually  bx^ought  forward 
as  evidence  of  the  occurrence  of  ovarian  pregnancy,  and  conse- 
quently, on  careful  examination  and  discovery  of  their  real  nature, 
the  evidence  fell  to  the  ground,  until  it  almost  seemed  an  attempt 
to  square  the  circle  when  any  one  tried  afresh  to  prove  the 
existence  of  ovarian  pregnancy.  A  case  reported  at  the  International 
Congress  of  Gyngecology  in  Amsterdam  (1899)  by  Van  Tussenbroek 
is  the  first  definitely  proved  case  of  ovarian  pregnancy. 

'  On  opening  the  abdomen,  a  great  quantity  of  dark  blood  gushed  forth. 
The  uterus  was  soft  nnd  somewhat  enlarged.     The  left  ovary  and  tube  were 

*  Jour,  of  Obstet.  and  Gyn.,  Sept.,  1903. 


692  DISEASES   OF    WOMEN. 

normal ;  at"  the  right  ovary  was  found  a  tumour  as  large  as  a  walnut,  to 
which  blood-clots  adhered.  The  right  ovary  and  tube  were  removed.  The 
tube  was  quite  normal ;  the  fimbrise  were  somewhat  conglutinated,  but  the 
lumen  was  free.  There  were  no  adhesions  between  ovary  and  tube.  The 
tumour  with  the  ovarj'  showed  near  its  top  the  place  of  rupture,  from  which 
a  ruddy  fringe  came  forth.  After  being  hardened,  the  specimen  was  opened 
by  a  median  section  going  through  the  fringed  opening.  By  this  section  the 
gestation-sac  in  the  tumour  was  cut  in  two  halves,  and  an  embryo  appeared 
of  about  12  mms.  in  length,  fixed  by  a  short  and  thick  umbilical  cord.  Micro- 
scopical investigation  showed  that  the  impregnated  0AT.im  had  developed 
within  a  Graaiian  follicle.  This  was  proved  by  the  fact  that  the  wall  of 
maternal  tissue  which  surrounded  the  ovum  showed  the  structure  of  the 
ruptured  Graafian  follicle — the  well-known  corpus-luteum.  Decidual  trans- 
formation of  the  connective  tissue  in  the  ovisac  was  nowhere  to  be  found.' 

Leopold's  conditions  necessary  to  characterize  a  pregnancy  as 
ovarian  are :  (1)  The  Fallopian  tube  and  fimbriae  must  be  com- 
pletely isolated  from  the  structure  of  the  foetal  sac  ;  (2)  the  uterus 
must  be  united  to  the  sac  by  the  ovarian  ligament ;  and  (3)  the 
ovary  on  the  gravid  side  should  be  absent,  and  its  tissue  should 
have  spread  into  the  wall  of  the  sac. 

These  conditions  are  now  proved  to  have  been  fulfilled  in  many 
cases,  and  the  occurrence  of  ovarian  pregnancy  is  placed  beyond 
doubt.  The  sac  is  generally  pediculated,  as  in  other  ovarian  tumours. 
Owing  to  the  situation,  it  is  doubtful  whether  abortion  can  occur 
with  expulsion  of  the  ovum  ;  but  haemorrhage  may  occur  into  the  sac, 
causing  a  heematoma  and  killing  the  foetus,  and  leading  to  secondary 
rupture  of  the  sac.  Molar  transformation  is  jDrobably  not  less 
frequent  than  in  tubal  cases ;  but  owing  to  the  absence  of  muscular 
tissue,  and  to  the  vascular  hilum  of  the  ovum  being  seldom  involved, 
when  rupture  takes  place  it  is  less  sudden,  and  generally  accompanied 
with  less  shock.  No  true  decidua  has  been  made  out  so  far  in  ovarian 
pregnancy,  but  decidual  cells  have  been  found  in  the  ovarian  tissue 
about  the  sac.  It  may  be  noted  here  that  in  uterine  pregnancy 
decidual  cells  have  been  found  in  the  ovary,  tube,  peritoneum,  and 
cervix,  both  in  its  canal  and  its  vaginal  surfaces. 

Abdominal  Pregnancy. — It  is  now  universally  admitted  that 
almost  all  the  cases  of  primary  abdominal  pregnancy  that  have 
been  recorded  belong  properly  to  the  category  to  be  presently  de- 
scribed as  Tubo-abdominal ;  i.e.  a  primary  tubal  gestation-sac  has 
ruptured,  and  allowed  the  foetus  to  go  on  growing  in  the  abdominal 
cavity.  Leopold  has  described  a  case  of  intra-uterine  pregnancy  in 
which  the  uterus  ruptured,  and  the  foetus  went  to  term  abdominally 


EXntA-UTLUUMJ  I'liEGKANCY.  G93 

Arrest  in  the  abdominal  cavity  between  the  ovary  and  tube  is 
probably  always  immediately  fatal  to  the  unprotected  ovum.  The 
peritoneum  eats  up  the  ovum.  Leopold  has  proved  experimentally 
that  conceptions  of  the  first  month  are  (][uickly  and  completely  ab- 
sorbed. 

Tubal  Pregnancy. — ^The  Fallopian  tube  is  not  adapted  for 
carrying  a  developing  ovum  till  full  term.  The  ovum  perforates 
the  tube,  and  leads  either  to  rupture  or  to  expulsion  of  the  ovum 
through  the  open  fimbriated  end  as  a  'tubal  abortion.'  In  the 
event  of  rupture,  the  ovum  may  continue  to  grow ;  according  to 
the  direction  in  which  rupture  takes  place,  three  later  developments 
of  tubal  pregnancy  may  be  distinguished  :  (a)  Tubo-abdominal,  in 
which  there  is  secondary  invasion  of  the  abdomen ;  (&)  Tubo-liga- 
mentary,  in  which  there  is  secondary  invasion  of  the  broad  ligament 
and  sub-peritoneal  tissues ;  (c)  Tubo-uterine,  in  which  there  is 
secondary  invasion  of  the  uterus.  Each  of  these  forms  may  present 
one  or  more  further  developments ;  and  the  following  table  shows 
at  a  glance  the  natural  history  of  tubal  pregnancy,  when  left  to 
itself  : — 

I.  Early  rupture  (before  sixth  or  eighth  week).     Sudden  and 

rapidly  fatal  haemorrhage  unless  operated  upon. 
II.  Tubal  abortion  (usually  before  eighth  week).      Formation 

of  a  tubal  mole  and  haemorrhage  from  the  open  end  of  the 

tube. 

1.  Complete  tubal  abortion.     The  mole  is  expelled  from  the 

tube  and  lies  outside  it  in  the  midst  of  the  blood-clots. 

2.  Incomplete   tubal  abortion.     The  mole   is  I'etained  in  the 

tube. 
III.   Later  rupture  (usually  eighth  to  twelfth  week).     In  every 
case  the  placenta  remains  directly  connected  with  a  part 
or  whole  of  the  tube. 
1.   Tubo-abdominal  invasion    (abdominal    pregnancy).      The 
foetus  always  lies  above  the  placenta ;  the  position  of 
which  leads  to  three  varieties. 
(«)   The    placenta    is    in    the    main    gestation-sac,    and 
covered  by  reflections  of  the  amnion. 

(b)  The  placenta  is  fastened   to  opened-out  tube,  back 

of  uterus,  and  adjacent  structures. 

(c)  The  placenta  remains  wholly  in  the  tube,  through  a 

rent  in  which  the  cord  passes  to  the  fcetus,  which  is 
lying  invested  by  amnion  in  the  abdominal  cavity. 


694 


DISEASES   OF   WOMEN. 


2.  -Tuho-ligamentary  invasion  (mesometiic  pregnancy).     The 

placenta  always  lies  primarily  above  the  fcetus  ;  the 

direction  of  growth  of  the  ovum  leads  to  two  varieties, 

(a)  Anterior,  or  sub-peritoneo-abdominal,  in  which   the 

peritoneum  is  stripped  up  antei'iorly. 
(6)  Posterior,    or    retro-peritoneal,    in    which    the    peri- 
toneum is  stripped  up  posteriorly. 
In  either    case  the  broad   ligament    sac    may   again 
rupture,  leading  to — 

3.  Tuho-Ugamentary-ahdominal  invasion.     Here  the  placenta 

remains  in  the  broad  ligament  sac,  through  a  rent  in 
which  the  cord,  invested  by  amnion  in  the  peritoneal 
cavity,  passes  to  the  foetus. 

4.  Tuba-uterine  invasion   (interstitial  pregnancy).     Rupture 

usually  occurs  before  the  sixteenth  week,  into— 
(a)  The  abdominal  cavity  ;  a  very  fatal  accident. 
ih)  The  uterine  cavity.     It  is  possible  that  this  may  go 
on     to     term,     simulating    normal     intra -uterine 
pregnancy. 
It  must  be  remembered  that,  whenever   rupture  occurs,  either 
early  or  late,  as  indicated  in  the  above  table,  the  embryo  may  either 

perish  at   once,  or  go 
>k  ~^>-r-  on  developing,  accord- 

ing to  the  amount  of 
interference  with  the 
placenta  involved  in 
the  accident.  We  are. 
of  course,  speaking  of 
cases  where  no  sur- 
gical interference  is 
resorted  to.  When  the 
foetus  dies  at  an  early 
stage  of  pregnancy,  it 
generally  undergoes  a 
process  of  absorption, 
and  completely  dis- 
appears ;  but  when  it 
has  attained  a  greater 
development,  it  becomes  mummified,  or  is  changed  into  adipocere. 
Such  a  foetus  may  remain  many  years  in  the  abdomen,  and  give  rise 
to  no  symptoms.     In  other  cases,   after  the  lapse  of    a  longer  or 


Fig.  472.  —  Extha-Uteeine  Peegnancy.  Fcetus, 
Sao,  and  Ovaey.  Euptuee  of  Ampulla. 
(Howard  Kelly.) 

Half  natural  size.     Operation  by  Peck,  of  Yonugs- 
towD,  U.S.     Kecovery. 


EXTnA-rTEniSK   PJtEaSAyCV. 


G'J5 


shorter  time,  the  sac  containing  the  foetus  may  undergo  suppuruliun, 
and  result  in  ;ux  abscess  which  discharges  through  the  bladder, 
rectum,  vagina,  or  externally;  the  contents  of  such  an  abscess 
consist  largely  of  foetal  bones.  Thus,  in  a  case  recorded  by  Cui-rier, 
in  which  abdominal  section  was  undertaken  fourteen  years  after 
the  occurrence  of  ectopic  gestation,  on  ac- 
count of  septic  development,  a  quantity  of 
offensive  fluid  was  found  in  the  abdomen, 
and  foetal  bones,  a  hundred  and  twenty-six 
in  number,  were  removed.  In  several  re- 
corded cases,  as  in  one  of  Mayo  Robson's, 
the  foetus  had  been  converted  into  a  litho- 
paedion.  Leopold  removed  a  lithopiigdion  of 
thirty  years'  duration  ;  this  was  a  case  of 
ovai'ian  pregnancy. 

Pathology. — The  tube  in  which  an  oosperm 
has  become  arrested  undergoes  certain 
changes  ;  its  vascularity  greatly  increases, 
and  its  walls  become  thickened.  According 
to  Clarence  Webster,  a  true  decidua  forms, 
as  in  the  case  of  uterine  pregnancy.  Bland- 
Sutton  and  others  deny  that  there  is  any 
decidua  formed.  In  any  case,  as  Taylor 
points  out,  a  special  zone  of  mucous  mem- 
brane differentiates  into  a  potential  decidua 
serotina,  and  within  this  zone  the  chorionic 
villi  develop.  It  is  a  remarkable  fact  that 
in  tubal  gestation  a  decidua  is  always  formed 
within  the  uterus. 

Considerable  light  has  been  thrown  on  the 
whole  subject  of  the  attachment  of  the  ovum 
within  the  last  few  years ;  the  successive 
steps  in  the  process  may  be  stated  histori- 
cally. 

In  1889  Hubrecht  published  a  monograph 
on  the  placentation  in  the  hedgehog,  and  therein  he  introduced 
new  ideas  and  new  names  which  have  now  been  generally  accepted 
in  the  embryology  of  the  higher  mammals. 

The  main  point  he  makes  clear  is  that  the  ovum  is  the  active 
agent,  and  builds  its  own  bed  or  placenta,  with  the  passive  co- 
operation  of    the    endometrium,    i)i   opposition    to    the    generally 


Fig.  473. — LiiHOPiEDiox 

REMOVED  FROM  THE  Ab- 

DosnxAL  Cavity  Four 
Years  after  a  False 
Labotr.  (Howard 
Kelly.) 

Placental  attachment  to 
right  tube.  Peculiar 
membrane  covering 
features  and  part  of 
body,  with  a  depcisit  of 
calcareous  salts  in  it 
and  the  skin.  Other 
portions  of  tiie  skin 
leathery  and  converted 
into  adipocere. 


696  DISEASES   OF   WOMEK 

accepted  notion  that  the  uterine  endometrium  enfolds  the  ovum,  and 
prepares  and  forms  the  placenta.  The  primitive  epiblast,  growing 
rapidly  into  a  thick  layer  of  cells,  becomes  a  special  organ  for 
nutrition.  The  true  embryonic  epiblast  is  a  very  small  portion. 
The  trophic  epiblast  is  termed  the  trophdblast.  It  actively  eats  up 
the  maternal  tissues,  and  by  its  means  the  ovum  bores  its  way  into 
the  mucous  membrane,  destroying  the  epithelium  and  other  tissues 
until  it  has  become  submucous.  The  hole  of  entrance  is  closed  by 
blood-clot,  which  later  on  organizes.  The  trophoblast  eats  into  and 
forms  intimate  connections  with  the  maternal  blood-vessels,  and  is 
itself  permeated  by  the  foetal  mesoblastic  blood-vessels,  of  which  it 
forms  the  chorionic  epithelium  of  the  villi.  We  can  thus  under- 
stand how  it  is  able  to  take  on  malignant  action,  and  form  chorion- 
epithelioma,  when  it  is  remembered  that  it  began  life  as  a  devouring 
trophoblast.* 

The  action  of  the  trophoblast  ceases  at  the  seventh  week,  and 
the  villi  have  no  power  of  destroying  maternal  tissue.  The  epi- 
blastic  cells  of  the  trophoblast  become  the  deep  Langhans  layer 
of  cubical  clear  cells,  which  by  changes  form  the  outer  layer  of 
opaque  multinucleated  protoplasm,  without  definite  cell  boundaries, 
termed  the  syncytium. 

The  maternal  reaction  to  this  invasion  by  the  ovum  is  the  forma- 
tion of  the  decidua.  This  decidua  is  formed  by  changes  in  the  cells 
of  the  stroma  of  the  endometrium  and  the  glands.  The  cells  become 
epithelioid  in  character,  i.e.  their  bodies  grow  out  of  proportion  to 
the  nuclei ;  glycogen  is  present  in  them.  The  glands  increase  their 
lumina,  while  their  epithelium  proliferates,  becoming  cubical. 

The  decidual  epithelioid  cells  are  affected  chiefly  in  the  superficial 
layers  of  the  endometrium,  and  thus  form  the  compact  layer  of  cells 
of  the  decidua,  resembling  squamous  epithelium ;  while  the  dilated 
glands  form  the  spongy  layer  of  the  decidua. 

Just  the  same  process  goes  on  in  the  tube  as  in  the  uterus,  when 
the  ovum  stays  there  and  develops,  and  the  differences  between  the 
two  gestations  are  entirely  due  to  the  differences  in  anatomy  of  the 
tube  wall  and  the  uterine  wall. 

Between  the  folds  of  mucous  membrane  in  the  tube  the  epithelium 
rests  directly  upon  the  muscle,  save  for  a  very  thin  intervening  layer 
of  connective  tissue,  of  which  there  is  a  greater  quantity  in  the  folds. 
(There  is  a  thicker  connective  tissue  layer  in  cases  of  salpingitis.) 
The  ovum  embeds  itself  in  the  tube  in  three  ways :  {a)  columnar 

*  See  cljapter  on  Chorion-epithelioma. 


EXTIiA-UTERlSE  PUEnXAyCY.  097 

embedding,  i.e.  in  a  fold  :  this  generally  leads  to  abortion,  as  the 
fold  is  not  large  enough  to  contain  for  long  a  growing  ovum  ; 
{b)  between  or  by  two  folds  ;  (c)  intercolumnar  embedding  into 
mucous  membrane  between  two  folds. 

The  trophoblast  burrows  practically  at  once  into  muscle,  as  there 
is  little  or  no  decidual  formation.  Whereas,  in  the  uterus,  it  opens 
into  capillaries  and  small  arteries  and  veins  which  bleed  only 
slightly,  here  it  may  at  once  open  large  vessels,  with  copious 
bleeding,  whose  pressure  overcomes  the  resistance  of  the  foetal  cells, 
and  the  bleeding  enters  the  ovum,  killing  it,  or  pours  forth  by  the 
tube  or  directly  into  the  peritoneal  cavity.  In  addition,  the  tube 
does  not  grow  fast  enough  to  keep  pace  with  the  growth  of  the 
ovum,  so  that,  later,  rupture  takes  place  from  overdistension  of 
the  tube. 

The  ruptures  up  to  the  seventh  week  are  caused  by  the  erosive 
action  of  the  trophoblast,  which  then  ceases.  The  peritoneum  may 
be  directly  eaten  through  by  the  trophoblast,  or  secondarily  rup- 
tured by  the  foi'ce  of  blood  from  an  eroded  large  artery.  In  the 
latter  case  a  spurting  artery  may  be  found  on  abdominal  section. 
Seams  and  contraction  of  the  tube  itself  may  lead  to  rupture  when 
the  tube  is  partially  eroded. 

After  the  seventh  week  mechanical  causes  of  rupture  ai-e  practi- 
cally the  sole  ones,  with  the  exception  of  bleeding  which  acts  in- 
directly in  a  mechanical  manner.  The  abdominal  ostium  of  the 
tube  is  generally  closed  after  the  seventh  week,  and  thus  the  pressure 
is  directed  upon  the  thinned  tubal  wall. 

Tubal  abortion  is  generally  caused  by  the  trophoblast  eating 
through  the  capsularis  into  the  lumen  of  the  tube,  or  by  htemorrhage 
from  eroded  vessels  bursting  into  the  lumen. 

Incomplete  abortion  is  common,  because  the  villi  are  so  deeply 
inserted  into  the  tubal  structures  (muscle)  that  they  cannot  come 
away ;  that  is,  no  line  of  cleavage  can  be  formed  in  the  tube  owing 
to  the  want  of  depth  and  proper  formation  of  the  mucous  membrane. 

The  abdominal  ostium  of  the  tube  is  closed  when  the  pregnancy 
is  near  this  end  of  the  tube,  and  later  on  by  clot,  and  this  closure, 
in  all  tubal  cases,  leads  to  the  late  rupture  of  the  tube. 

A  tubal  embryo  is  peculiarly  liable  to  perish  from  haemorrhage 
which  results  from  erosion  of  blood-vessels  by  the  trophoblast, 
whereby  the  ovum  is  converted  into  a  'mole.'  This  bleeding  gene- 
rally bursts  through  the  capsularis  into  the  lumen  of  the  tube,  but 
if  less  resistance  be  offered  in  the  direction  towards  the  peritoneum, 


698 


DISEASES   OF    WOMEN. 


it  goes  this  way.  The  bleeding  is  now  considered  to  be  from  the 
maternal,  not  the  fcebal,  vessels,  and  to  penetrate  the  sub-chorionic 
chamber  merely  by  force. 

Tubal  Mole. — A  tubal  mole  is  an  ovoid  mass  averaging  5  cms. 
in  its  long,  and  3  cms.  in  its  short,  diameter.  On  cutting  a 
mole  open,  the  amniotic  cavity  can  be  usually  recognized,  situated 
excentrically  in  the  midst  of  the  blood-clot ;  and  within  the 
amniotic  cavity  the  embryo  may  be  found  (Fig.  474).  Micro- 
scopically, the  mole  is  recognized  as  such  by  the  presence  of  chorionic 
villi  embedded  in  blood-clot.  The  accident  that  leads  to  the  forma- 
tion of  the  mole  has  one  of  two  effects  :  tuhal  abortion,  in  which  the 
mole  is  partly  or  wholly  detached  from  the  tube,  and  haemorrhage 


CORD     AMNION 

Fig.  -±74. — A  Tubal  Mole.     (After  Walter.) 
Natural  size. 


Fig.  475. — A   Uterine   De- 

CIDUA  expelled  IN  A  CaSE 

OP     Tubal     Pregnancy. 
(After  Bland-Sutton.) 


occurs  into  the  abdominal  cavity,  through  the  open  fimbriated  ex- 
tremity of  the  tube  ;  or  tuhal  rupture,  in  which  haemorrhage  takes 
place  into  the.  broad  ligament  or  peritoneal  cavity,  according  to  the 
position  of  the  rupture.  In  either  case  the  accident  is  marked  by 
the  onset  of  uterine  htemorrhage,  of  which  a  characteristic  feature 
is  the  presence  amid  the  clots  of  fragments  of  the  decidua  from  the 
uterus.  Sometimes  the  decidua  is  expelled  whole,  or  in  two  or  three 
main'  pieces,  forming  a  more  or  less  complete  cast  of  the  uterine 
cavity  (Fig.  475)  ;  it  is  then  a  very  characteristic  object,  consisting 
of  a  fibrous  non-vascular  membrane,  triangular  in  shape,  with  orifices 
at  the  angles  corresponding  to  the  apertures  of  the  uterine  ostia  of 


Clarence  Webster  has  recently  recorded  a  case  of  undoubted  ovarian 
pregnancy.  The  detailed  description  of  the  histological  features  of  the  tumour 
will  be  found  in  the  American  Journal  of  Ohstetrics,  July,  1904  The  ovum 
was  situated  entirely  within  the  substance  of  the  ovary.  There  was  no 
corpus  luteum  present  in  the  gestation  sac,  showing  that  the  ovum  was  not 
fertilized  in  a  ripe  follicle.  Webster,  advocating  the  development  of  the 
human  fertilized  ovum  in  tissue  derived  from  the  Miillerian  duct,  and  the 
extension  of  Miillerian  tissue  into  the  ovary,  taken  in  conjunction  with 
the  observations  of  Schmorl,  and  others,  which  showed  the  occasional 
occurrence  of  decidual-like  cells  in  the  ovary  in  cases  of  uterine  pregnancy, 
suggests  that  these  areas — detached  portions  of  Miillerian  tissue — through  a 
special  genetic  reaction  determine  the  embedding  and  growth  of  a  fertilized 
ovum  in  the  ovary.* 

*  Williamson,  Jom;-.  Oh?t.  and  Gyn.  Brit.  Emp.,  Sept.,  1904. 


PLATE    LXXIII. 


g.2 

•r;   a 
o   3 


O     03 


Q  -5 


'.3   a 

^     0) 


bB.g  ° 


03 

Unruptured  Tubal  Gestation  in  which  the  Ebibryo  hah  Perished  during 
THE  Fourth  Week  from  Haemorrhage  into  the  Membranes.  (Mary 
Scharlieb.) 

Removed  successfully  by  operation  tLree  months  later. 

[To  face  p.  G99. 


KX  TUA-  LITE  J!  IS  K   1  'liK(  I  .\\  1  -\'C' ) : 


(JO!) 


the  tubes  and  the  internal  os  respectively,  and  with  a  shaggy  ex- 
terior. Simihir  casts  are  found  in  membranous  dysmenorrhcea,  tlic 
main  difference  being  that  the  latter  are  smaller,  and  are  passed  at 
recurrent  intervals  coinciding  with  the  menstrual  periods. 

Winckel  says  that  a  decidual  cast  of  the  uterus  occurs  in  nearly 
every  case  within  the  first  four  months,  even  when  the  pregnancy 
goes  to  term. 

Symptoms  and  Signs  of  Tubal  Pregnancy. — Up  to  the  time  of 
the  sixth  or  eighth  week,  there  is  little  to  distinguish  a  tubal  from 
a  uterine  pregnancy,  beyond  the  fact  that  there  may  be  a  little 
aching  in  one  side  ;  if  an  examination  be  made,  the  uterus  will  be 
found  rather  smaller  than  it  should  be  for  the  term  of  pregnancy. 


t,^trop^exi  !lzzl>e  ■ 


JuLolI  Ireoriancy, 


Fig.  476. — Tubal  Pregxaxcy  ix  a  Case  ix  which  the  Fallopian  Tubes  weue 

ATROPHIED,   AVITH   ACCIDENTAL   KeXT    IN    THE   NoN-IMPREGNATED    TUBE. 

(Taylor.) 
Specimen,  Mason  College  Museum. 

and  one  tube  may  be  made  out  to  be  enlax'ged.  A  gravid  tube  is, 
however,  rarely  discovered  before  rupture.  When  rupture  occurs, 
and  the  pregnancy  is  uninterrupted,  there  may  be  a  total  absence 
of  symptoms  pointing  to  an  abnormal  gestation,  and  the  patient 
may  go  on  to  term,  expecting  an  ordinary  confinement. 

Symptoms  and  signs  must  now  be  considered  as  met  with  in  the 
following  circumstances  : — 

Early  tubal  rupture. 

Tubal  abortion. 

Later  tubal  rupture. 

Tubo-abdominal  pregnancy. 

Tubo-ligamentary  pregnancy. 

Tubo-uterine  pregnancy. 


700 


DISEASES   OF   WOMEN. 


Early  Tubal  Rupture. — The  history  of  this  rare  occurrence  is 
that  a  woman  in  good  health,  whose  monthly  pei'iod  is  about  a 
week  overdue  or  irregular,  is  overtaken  by  a  sudden  pain  and 
alarming  collapse,  quickly  followed  by  all  the  signs  of  profuse 
internal  haemorrhage.  If  surgical  aid  be  not  forthcoming,  the 
patient  dies  after  an  illness  of  eight  to  forty-eight  hours'  duration. 
On  vaginal  examination,  there  may  be  nothing  felt  except  a  vague 
boggy  fulness  in  the  pouch  of  Douglas ;  but  if  the  bleeding  has 
been  going  on  for  some  time,  there  will  probably  be  dulness  on 
percussion  above  the  pubes  and  in  the  flank.  According  to  Taylor, 
the  tubes  in  these  cases  are  nearly  always  ill-developed  and  small, 
with  the  muscular  coat  defective,  the  uterine  ostium  small,  and 
abdominal  ostium  patent. 

Tubal  Abortion. — This,  as  explained,  means  the  outpouring  of 


Fig.  477. — Tubal  Aboetion,  showing  the  Distended  Cavity,  the  Greater 
Diameter  of  the  Clot  in  the  Ampulla  preventing  its  Escape.  (Howard 
Kelly.) 

!  Natural  size.     Operation.     Recovery. 

blood  through  the  abdominal  ostium,  together  with  the  formation  of 
a  mole.  The  latter  may  be  retained  within  the  tu.be  (Fig.  476), 
or  expelled  with  the  blood  into  the  peritoneal  cavity  (Fig.  478)  ; 
and  the  tubal  abortion  is  accordingly  described  as  complete  or 
incomplete.  Incomplete  abortion  is  A^ery  much  commoner  than 
complete,  since  the  union  of  the  villi  with  the  muscle  wall  is  so 
intimate  that  complete  separation  is  rare.     Complete  tubal  abortion 


PLATE   LXXIV. 


H^SIATOCELE    EeTEO-UTEKINE — TUBAL    ABORTION.      (BUSIM.) 

3,  ovum;exti-uded  from  tlie  tube  into  the  cavity  of  the  hsematocele ;  2,  cavity  of 
the  hasmatocele  sac  filled  with  extravasated  blood;  3  and  4,  wall  of  the 
hsematocele  sac ;  5,  fundus  uteri. 

[To  face  p.  700. 


PLATE   LXXY. 


D— 


J  I 

Instantaneous  Photograph  of  Eetro-utkeine  Hematocele  from  Rupture  of  the 

FcETAL  Sac  in  the  Isthmus  of  the  Left  Fallopian  Tube.     (Bumji.) 
A,  vermiform  appendix ;  C,  csecum ;  B,  sigmoid ;  1)   haematocele  sac ;  E,  fimbriated  end 
of  tube  ;  G,  isthmus  of  left  tube ;  H.  tubal  gestation  ;  I,  uterine  end  of  tube  ;  F,  right 
tube;  J,  fundus  uteri.  [To  face  p.  101. 


EXTRA  -  UTERINE   P  R  EG  XA  XC  Y. 


7(11 


is  accompanied  by  hjcmoi-rhage,  which  is  usually  severe,  but  is  not 
repeated,  and  may  not  l)e  fatal ;  but  with  incomplete  abortion  the 
tendency  to  bleeding  con- 
tinues as  long  as  the 
mole  is  retained,  just  as  a 
retained  placenta  leads  to 
continued  uterine  haemor- 
rhage. The  blood  may 
be  poured  out  abundantly, 
or  it  may  assume  the  cha- 
racter of  a  '  blood-drip,' 
as  Taylor  calls  it.  The 
eflfused  blood  is  called  a 
pelvic  hfematocele ;  this 
term  was  formerly  used 
to  describe  a  definite 
pathological  condition, 
whose  origin  was  not 
known.  Now  it  is  almost 
universally  regarded  as 
due  in  every  case  to  tubal 
pregnancy,  and,  as  de- 
scriptive of  a  separate  condition,  the  term  may  be  regarded  as 
obsolete.  Haematoceles  vary  in  character  :  when  due  to  tubal  abor- 
tion, the  blood  is  generally  circumscribed  so  as  to  form  a  definite 
tumour  ;  on  the  other  hand,  if  caused  by  tubal  rupture,  the  limiting 
membrane  may  be  slender  and  ill-defined,  and  liable  to  sudden  and 
marked  alterations  from  fresh  bleeding ;  or  the  escape  of  blood  may 
not  be  circumscribed,  but  '  diffuse,'  when  it  is  checked  only  by 
operation  or  death.  It  does  not  then  come  properly  under  the 
category  of  a  hsematocele.  From  this  description,  the  nature  of 
the  symptoms  of  a  tubal  abortion  may  be  inferred.  The  patient  is 
first  seized  with  a  sudden  faintness,  accompanied,  as  a  rule,  by 
sharp  pain  ;  this,  if  the  bleeding  be  free,  merges  into  a  deepening 
collapse.  When  the  latter  takes  the  form  of  a  blood-drip,  the 
patient  may  partially  recover,  although  liable  to  recurring  attacks 
of  collapse  when  the  retained  mole  leads  to  repeated  outpourings  of 
blood.  Sometimes  each  attack  is  accompanied  by  sharp  pain,  due 
to  '  tubal  colic  ; '  and  in  some  of  these  cases  it  is  found,  on  opening 
the  abdomen,  that  the  tube  has  repeatedly  filled  with  blood  which 
has  become  converted  into  a  clot  forming  a  cast  of  the  tube  ;  and 


Fig.  478. — Ecxcipic  Gestation,  showing  the 
Dilated  and  Thickened  Tube  with  the 
Adhesions  to  the  Ovary.   (Howard  Kelly.) 

In  this  case  a  perfect  tube  cast  was  thrown  oft 
into  the  abdominal  cavity.  Operation.  Ke- 
covery.     Three-fourths  natural  size. 


702 


DISEASES  -OF   WOMEN. 


that  each-  cast  has  been  expelled  with  a  fresh  accession  of  pain  and 
bleeding.     On  vaginal  examination  of  a  case  of  tubal  abortion,  a 

boggy  tumour  is 
found  occupying 
the  pouch  of  Doug- 
las ;  and  on  one  or 
other  side  a  swell- 
ing is  felt  in  the 
situation  of  the 
tube.  The  lateral 
swelling  is  more 
marked  in  cases 
of  incomplete  tubal 
abortion. 

Fig.  479. — HiEMATOCELE  Capsule  seen  fkom  within,         The  diagnosis  is 
"WITH  THE  Fimbriated  End  of  the  Tube  in  Posi-    completed    by    the 

TION.       (TaYLOE.)  ^.^^.^^,y  ^f  ^l^g  ^^gg^ 

which  elicits  the  fact  that  the  patient  had  missed  one  or  two 
menstrual  periods,  and  thought  herself  pregnant ;  she  may  state 
that  a  relatively  long  period  of  sterility  has  "elapsed  since  her  last 
pregnancy,  or  that  she  has  not  been  previously  pregnant. 

Later  Tubal  Rupture. — This,  like  tubal  abortion,  generally  takes 


Fig.  480. — Left  Ectopic  Gestation.     Euptuee  at  Juncture  of  the 

Ampulla  with  the  Isthmus.     (Hom'aed  Kelly.) 

Natural  size.     Operation.     Saline  injection  and  recovery. 


EXTRA-  LIERIXE  PREOXA^'C  Y. 


703 


place  between  the  eighth  and  twelfth  weeks  of  pregnancy — unlike 
the  early  rupture.  It  occurs  into  the  peritoneal  cavity  (Fig.  180) 
or  into  the  broad  ligament  (Fig. 


481);  and  the  symptoms  will 
vary  accordingly.  In  the  for- 
mer ease,  the  symptoms  are 
sudden  and  alarming  ;  in  the 
latter  case,  they  are  less  marked, 
and  may  be  followed  by  com- 
plete recovery.  The  history  of 
the  case  resembles  that  de- 
scribed under  tubal  abortion. 
The  condition  found  on  vaginal 
examination,  when  the  rupture 
is  intra-peritoneal,  is  hardly  dis- 
tinguishable from  that  found  in  Fig.  iSl 
the  case  of  tubal  abortion,  but 
when  the  rupture  is  mesometric, 


Broad  Ligament  Pkegxancy. 
Cavity    xx    the     Broad    Ligament. 

(Taylor.) 


vanlt  of  the  pregnancy ;  placenta 
(Taylor  says)  would  be  found  in  the 
roof  and  lateral  wall  of  the  chamber. 
It  lav  above  the  foetus. 


,1  •  £  1  4-^1 ,!•       The  tube  has  disappeared ;   rupture   of 

there  is  no  fulness  to   be   dis-       ^,         . , .,,     ,,  .  ^       ,  .  ,     „ 

the  middle  third,  vrhicu  torms  the 
covered  in  the  pouch  of  Dou- 
glas ;  on  the  other  hand,  the 
lateral  swelling  is  much  more 
marked.  A  large  proportion 
of  the  cases  formerly  described  as  pelvic  h^ematoma  belong  to  this 
category ;  it  is  the  only  kind  of  tubal  pregnancy  that  can  be  safely 
left  without  surgical  interference,  under  proper  observation ;  but 
even  these  cases  may  require  operation  sooner  or  later.  Later 
rupture  of  the  tube  may  result  at  once  in  the  death  of  the  fretus ; 
or  this  latter  may  continue  to  develop,  if  the  placental  attachments 
have  not  been  too  much  interfered  with,  into  one  of  the  forms  to 
be  next  described.  An  important  symptom  of  both  abortion  and 
rupture  of  a  gravid  tube  is  uterine  haemorrhage,  associated  with 
the  discharge  of  larger  or  smaller  portions  of  decidua,  as  previously 
described. 

Tubo-abdominal  Pregnancy. —  "We  have  said  that  this  condition 
may  go  on  to  full  term  without  any  suspicion  being  excited  that 
the  fcetus  is  not  within  the  uterine  cavity.  At  term  a  spurious 
labour  sets  in  ;  the  os  uteri  dilates  to  some  extent,  but  no  further 
progress  is  made.  The  medical  attendant  is  then  led  to  explore 
the  interior  of  the  uterus,  which  is  found  empty,  and  of  small  size. 
On  abdominal  palpation,  the  fcetal   limbs  may  be  made  out  much 


704  DISEASES   OF    M^OMEN. 

more  distinctly  than  is  consistent  with  intra-uterine  pregnancy.  If 
the  true  state  of  things  be  not  detected,  the  labour  pains  gradually 
cease,  the  fcetus  dies,  and  is  converted  into  adipocere  or  into  a 
lithopsedion  (Fig.  473). 

In  other  cases,  pregnancy  does  not  proceed  so  smoothly ;  the  sac 
may  contract  pelvic  adhesions,  and  become  incarcerated  in  the 
pouch  of  Douglas,  simulating  retroversion  of  the  gravid  uterus. 
Pelvic  inflanimation  then  commonly  supervenes,  and  this,  together 
with  the  pressure  symptoms,  will  generally  lead  to  surgical  inter- 
ference, and  to  a  discovery  of  the  true  state  of  matters. 

Tubo-ligamentary,  or  Mesometric,  Pregnancy.  —  Mesometric 
pregnancy  cannot  proceed  beyond  the  fourth  or  fifth  month  without 
giving  rise  to  serious  symptoms  and  well-marked  physical  signs, 
due  to  pressure  of  the  gestation-sac  on  the  pelvic  contents.  The 
symptoms  will  be  those  of  pelvic  inflammation  and  pressure ;  on 
examination,  a  swelling  will  be  detected  in  the  iliac  fossa,  and  the 
enlarged  and  pushed-up  uterine  fundus  will  probably  be  felt  in  the 
middle  line,  or  pushed  over  to  the  opposite  side.  On  vaginal 
examination,  the  broad  ligament  is  found  occupied  by  a  small  swell- 
ing, feeling  rather  like  an  inflamed  broad  ligament  cyst.  The 
symptoms  of  pregnancy — amenorrhcea,  morning  sickness,  and  milk 
in  the  breasts — may  be  well  marked ;  and  if,  in  addition,  there  is 
a  clear  history  of  an  attack  of  syncope  or  iliac  pain,  a  correct 
diagnosis  is  fairly  easily  arrived  at.  In  the  absence  of  such  history 
and  symptoms,  however,  the  diagnosis  may  be  very  difiicult ;  indeed, 
it  may  not  be  made  until  the  abdomen  is  opened. 

In  other  and  rarer  cases,  the  increasing  pressure  within  the 
broad  ligament  leads  to  secondary  rupture  of  the  gestation-sac ;  this 
is  specially  liable  to  occur  in  that  variety  of  mesometric  gestation 
in  which  the  foetus  lies  above  the  placenta,  since  the  restraining 
membrane,  consisting  of  foetal  envelopes  and  thinned-out  broad 
licament,  is  much  less  resistant  than  when  it  is  composed  of 
placenta.  When  this  accident  takes  place,  the  patient  is  again 
placed  in  jeopardy,  owing  to  the  risk  of  fatal  haemorrhage ;  but  if 
this  risk  be  averted,  the  foetus  will  probably  continue  to  develop, 
the  pregnancy  being  then  of  the  type  of  the  '  tubo-ligamentary- 
abdominal '  invasion  (see  under  Classification).  This  pregnancy,  like 
the  tubo-abdominal,  may  go  on  to  full  term,  and  the  same  sequence 
of  events  takes  place. 

Tubo-uterine,  or  Interstitial,  Pregnancy. — This  is  a  i-are  form  of 
ectopic   gestatiojjL   in   which    arrest   of    the   oyum    has  taken    place 


EXTRA-  UTEMINE   L'liEGNANCr. 


7U5 


within  the  portion  of  the  tube  near  the  uterine  t).stium.  As  a  rule, 
rupture  occurs  early,  and  it  is  one  of  the  most  rapidly  fatal  forms, 
owing  to  the  fact  that  the 
rent  involves  the  highly 
vascular  uterine  tissue.  But 
here  also  there  is  a  way  of 
escape  if  the  rent  open  ujj 
the  uterine  substance  in- 
stead of  passing  through  the 
peritoneal  coat.  The  later 
development  of  the  case  is 
that  secondary  rupture  takes 
place  into  the  uterine  cavity, 
or  into  the  peritoneum. 
Very  little  is  known,  how- 
ever, of  this  subject ;  and  it 
is  probable  that  some  cases 
at  least,  described  as  belong- 
ing to  this  class,  have  really 
been  instances  of  pregnancy 
in  the  rudimentary  horn  of 
a  uterus  unicornis. 

Rudolph  Smith  and  Her- 
bert "Williamson  recorded  an 
unusual  case  of  ectopic  ges- 


FiG.  482.  —  Ectopic  Gestation',  Tl'bo- 
UTERiNE  OR  Interstitial  Pregnancy. 
(Taylor.) 

The  sac  of  pregnancy  appearing  to  lie  across 
the  fundus  from  right  to  left.  lu  reality, 
as  pointed  out  by  Taylor,  the  unaltered 
part  of  the  fundus  lies  altogether  to  one 
side  of  this  sac  of  pregnancy  (Guy's  Hos- 

tation.*      The    patient    had 

last  menstruated  in  March,  1901.  On  January  17,  1902,  the  foetal 
movements  ceased,  and  the  foetal  heai't  could  not  be  heard.  A 
brown  and  watery  discharge  was  noticed.  Thirteen  days  later,  an 
attempt  was  made  to  deliver  the  foetus.  Three  months  later  the 
abdomen  was  opened,  and  a  tumour  lying  between  the  layers  of  the 
left  broad  ligament,  joined  to  the  uterus  by  the  base  of  the  broad 
ligament,  was  removed.  The  broad  pedicle  was  ligatured  in  five 
sections.  The  tumour  was  spherical  in  shape,  and  measured  21^ 
inches  in  cii'cumference.  The  greater  part  of  it  was  covered  by 
peritoneum,  with  enlarged  veins  lying  underneath.  The  only  portion 
devoid  of  peritoneum  was  a  triangular  area  near  its  lower  portion, 
marking  the  lines  of  reflection  of  the  two  layers  of  the  broad  ligament. 
The  relations  of  the  Fallopian  tube  to  the  round  ligament  and  the 
attachment  of  the  tumour  to  the  uterus,  are  shown  in  the  drawing. 
*  Jour.  Obstet.  Gyn.  Brit.  Einp.,  vol.  iii.  p.  '11. 

2  z 


706 


DISEASES   OF   WOMEN. 


The  lumen  of  the  Fallopian  tube  was  closed,  but  that  of  the  ostium 
was  not.  An  oval  fibrous  structure  represented  the  uterine 
■attachment  of  the  round  ligament.  Behind  the  broad  ligament  the 
ovary  was  seen,  with  the  ovarian  ligament  attached  directly  to  the 
wall  of  the  tumour.  The  cavity  of  the  tumour  was  occupied  by 
the  body  of  a  well-developed  child.  All  these  points  show  that  the 
origin  of  the  sac  was  uterine,  and  the  pregnancy  a  typical  cornual 
one.  The  authors  think  that  it  is  possible  that  the  pedicle  of  the 
tumour  was   originally  patent,  and  that   the  closure  of  the  canal 


Fig.  483.— Cornual  Pkegnanct.    (Kudolph  Smith  and  HERBEKT_WnLiAMSON.) 

occui-red  after  impregnation.  Murdoch  Cameron  suggests  that  there 
may  have  been  a  small  channel  or  tubule  in  the  cervix,  which  was 
afterwards  obliterated,  or  that  a  continuous  channel  was  formed  by 
one  Fallopian  tube  grasping  the  other.  Galabin,  Targett,  Murdoch 
Cameron,  J.  W.  Sinclair,  and  Bland-Sutton  have  each  recoi'ded 
cases  of  ectopic  gestation  going  to  full  term  without  rupture  of  the 
sac.  In  Sinclair's  case  the  pregnancy  was  regarded  by  him  as  tubal. 
Repeated  Ectopic  Gestation. — Many  cases  of  repeated  ectopic 
pregnancy  have  been  reported  :  for  instance,  Falk  of  Jena  operated 


EXTRA-  UTEEI^^'E  PREGNANCY. 


707 


upon  a  woman  who  Hrst  underwent  laparotomy  in  1894  for  tubal 
pregnancy  in  the  right  tube,  and  who  was  operated  upon  again  in 
1897  for  pregnancy  of  the  left  tube,  doing  well  on  each  occasion.* 

Diagnosis. — In  the  first  half  of  pregnancy  the  difficulty  is  to  make 
sure  that  this  is  present ;  in  the  second  half  the  trouble  is  to 
make  certain  that  the  gestation  is  extra-uterine.  The  main  points 
in  diagnosis  have  been  indicated  in  the  account  of  symptoms  and 
signs,  and  may  be  summarized  as 
follows  :  — 

(«)  Before  rupture  or  abortion, 
diagnosis  will  probably  be  made  by 
accident,  because  the  only  symp- 
tom, other  than  those  associated 
with  pregnancy,  is  pain  or  aching 
in  one  side.  No  doubt  in  most 
cases  there  are  obscure  pains,  and 
were  careful  bimanual  examina- 
tions made  more  often,  early  tubal 
pregnancies  would  be  diagnosed 
more  frequently.  If  these  lead  to 
examination,  a  swelling  will  be 
discovered  on  one  side  of  the 
uterus,  in  the  region  of  the  tube ; 
pulsating  vessels  will  be  felt  in 
the  corresponding  vaginal  vault; 
and  the  uterus  will  be  felt  to  be 
smaller  than  a  gravid  uterus  of 
the  same  period.  It  may  be  diffi- 
cult to  diagnose  the  case  from  one  of  diseased  appendages  or  a 
small  ovarian  or  broad  ligament  cyst. 

(&)  At  the  time  of  rupture  or  abortion,  the  diagnosis  of  a  typical 
case  is  not  difficult,  if  the  following  points  be  noted :  The  patient  may 
have  been  sterile  for  some  years,  but  is  otherwise  in  good  health ;  she 
has  missed  one  or  two  periods,  after  which  there  has  been  uterine 
haemorrhage,  dark  in  colour,  moderate  in  amount,  and  persistent  in 
its  course.  With  the  blood  thei-e  has  been  the  passage  of  some 
membrane,  as  a  complete  decidua,  in  several  pieces,  or  in  shreds ; 
the  onset  of  bleeding  has  been  accompanied  by  sharp  one-sided 
pain  and  by  collapse,  and  there  may  have  been  repeated  attacks  of 
this  kind,  or  the  collapse  has  been  continuous  and  progressive.     On 

*  ZeitscUHj'tf.  Geh.  n.  Gyn.,  P,;3,  2. 


Fig.  4Si. — Double  Uterus  and 
Vagina.     (Taylos.) 

Pregnancy  in  right  uterus. 


708  DISEASES   OF    WOMEN. 

examination,  marked  pulsation  is  felt  in  one  vaginal  vault,  and  on 
this  side  there  is  a  tubal  tumour  which  may  or  may  not  be  associated 
with  a  swelling  (htematocele)  in  the  pouch  of  Douglas,  displacing 
the  uterus  forwards  or  to  one  side  ;  if  explored,  the  uterus  is 
found  empty,  and  there  may  be  milk  in  the  breasts,  and  other 
symptoms  of  pregnancy.  It  is  often  difficult  to  diagnose  between 
tubal  rupture  and  tubal  abortion.  Sudden  and  profound  shock, 
associated  with  a  swelling  in  the  pouch  of  Douglas,  is  indicative 
of  intra-peritoneal  rupture ;  less-marked  collapse,  especially  if  re- 
current, together  with  post-uterine  swelling,  points  to  tubal  abor- 
tion ;  slight  shock  v/ith  a  marked  swelling  in  the  broad  ligament  is 
probably  extra-peritoneal  rupture. 

(c)  Extra-uterine  gestation  at  or  about  mid-term,  after  the 
primary  rupture  has  been  recovered  from,  will  present  some  of 
the  symptoms,  but  none  of  the  signs,  of  uterine  pregnancy. 

About  this  time  the  conditions  which  may  be  mistaken  for  extra- 
uterine pregnancy  are — 

1.  Simple  abortion.  In  this  case  the  operative  interference  by 
dilatation  and  curetting  may  dangerously  affect  an  extra-uterine 
pregnancy.  The  histories  of  simple  abortion  and  of  extra  uterine 
pregnancy  are  often  similar,  but  the  physical  signs  are  quite  dif- 
ferent, and  a  careful  bimanual  examination  with  an  empty  bladder 
will  differentiate  them. 

2.  Intra-uterine  pregnancy  complicated  by  pelvic  tumour.  Here 
care  and  caution  are  required,  as  otherwise  abortion  may  be  in- 
duced. As  there  are  generally  no  urgent  symptoms,  in  these  states 
of  doubt  a  little  time  will  soon  decide  where  the  foetus  is  growing. 

3.  Retroflexion  of  the  gravid  uterus.  This  is  a  very  important 
condition  to  bear  in  mind.  And  especially  we  have  to  recollect  the 
possibility  of  an  extra-uterine  pregnancy  before  any  attempt  is 
made  to  reduce  a  supposed  retroflexed  pregnant  uterus.  Retention 
of  urine  is  more  common  in  gravid  retroflexion,  and  uterine  colic, 
with  membranous  casts,  in  ectopic  pregnancy. 

4.  Pyosalpinx.  When  in  a  case  of  double  pyosalpinx  there  is 
amenorrhoea,  the  case  may  be  very  difficult  to  diagnose  from  extra- 
viterine  pregnancy.  Especially  is  this  so  when  the  signs  of  old 
gonorrhoea  may  perhaps  be  established,  since  gonorrhcea  is  also 
known  as  a  cause  of  extra-uterine  pregnancy. 

However,  the  history  will  usually  clear  up  the  diagnosis.  The 
more  recent  the  gonorrhcea,  the  less  likely  is  ectopic  gestation. 

5.  Myoma.     In  this  case  a  chronic  tubal  or  peritubal  haematocele 


EXTMA'UTEEINE  PREGNANCY.  700 


of  firm  consistence  and  closely  applied  to  the  uterus  may  hv  mis- 
taken for  a  myoma.  Uterine  liiismorrhage  will  occur,  and  a  gloI)ul;u' 
mass  united  to  the  uterus  will  be  felt. 

Usually  the  characteristic  earlier  history  of  extra-uterine  preg- 
nancy will  be  obtainable,  and  the  acute  abdominal  pain  is  not  found 
in  myoma. 

6.  Twisted  pedicle  tumours  of  the  tube  or  ovary.  These  are  usually 
not  so  intimately  connected  with  the  uterus  as  extra-uterine  gestation. 

(d)  Extra-uterine  gestation  at  term  is  sometimes  suspected  when 
the  fa^tal  parts  can  be  felt  with  abnormal  distinctness  on  abdominal 
palpation ;  but  the  diagnosis  is  only  definitely  made  when  the 
uterus  is  explored  at  the  onset  of  labour  and  found  empty. 

When  the  abdomen  is  opened,  ectopic  gestation  can  be  diag- 
nosed with  certainty  by  finding,  (a)  the  foetus,  or  (b)  chorionic  villi 
in  the  tube.  The  presence  of  a  mole  may  be  regarded  as  patho- 
gnomonic. 

Prognosis. — The  gravest  complications  of  tubal  pregnancy  are 
early  rupture,  later  intra-peritoneal  rupture,  and  tubo-utei'ine  rup- 
ture. In  the  case  of  rupture  into  the  broad  ligament,  surgical 
intervention  is  not  so  urgent,  and  in  some  cases  is  not  necessary. 
If  pregnancy  continue,  the  patient's  life  is  constantly  threatened 
by  the  risk  of  secondary  rupture,  grave  j^ressure  symptoms  or 
septicaemia.  These  risks  persist  after  the  full  term  of  pregnancy 
has  passed.  When  operation  is  undertaken,  the  prognosis  is  good, 
except  in  the  case  of  operation  at  term  with  a  still  active  placenta ; 
in  the  latter  case,  the  operation  is  one  of  the  most  formidable  in 
the  whole  range  of  surgery. 

Treatment. — It  may  be  stated  generally  that  whenever  tubal 
gestation  is  discovered,  operation  for  the  removal  of  the  foetus  and 
sac  should  be  undertaken  at  the  earliest  possible  moment.  The 
question,  however,  has  to  be  considered  in  some  further  detail. 

At  the  time  of  primary  rupture  or  abortion,  operation  is  required 
in  every  instance,  with  the  possible  exception  of  cases  of  rupture 
into  the  broad  ligament,  where  it  is  allowable  to  wait  and  watch. 
The  risk  of  operation  is  far  less  than  the  continuance  of  the  bleed- 
ing, which  may  not  cease  until  life  is  extinct.  The  operation  is 
quite  simple,  and  consists  of  the  evacuation  of  the  blood-clots,  and 
the  removal  of  the  affected  tube  and  ovary,  or  rather  the  ligature 
of  the  ovarian  and  uterine  arteries  or  their  branches.  In  an  early 
ampullary  gestation  it  is  possible  that  the  ovary  and  more  than  half 
the  tube  may  be  saved.     Olshausen  advocates  conseivative  resection 


710  DISEASES   OF    WOMEN. 

of  the  tube  in  suitable  early  cases.  The  method  of  operation  will 
vary  according  as  the  indication  for  operation  is  diffuse  haemorrhage 
or  a  localized  tumour  (Taylor).  Operations  for  haemorrhage  may  be 
required  in — 

1.  Early  rupture  of  the  tube. 

2.  Later  rupture  of  the  tube. 

3.  Secondai-y  rupture  of  a  broad  ligament  pregnancy  or  peritubal 

hsematocele. 

4.  Rupture  of  a  tubo-uterine  pregnancy. 

The  operation,  being  one  of  emergency,  may  involve  abdominal 
section.  When  operating  for  a  localized  haematocele  or  for  an 
intact  pregnancy,  some  surgeons  advocate  vaginal  coeliotomy,  whilst 
others  prefer  abdominal  section.  In  the  main,  it  is  a  question  of 
individual  predilection.  For  a  true  retro-uterine  htematocele,  the 
best  plan  will  generally  be  incision  of  the  mass  through  the  posterior 
fornix.  For  unruptured  tubal  pregnancy,  colpotomy  is  easy  if  the 
vagina  be  capacious.  For  mesometric  pregnancy,  where  the  foetus 
lies  below  the  placenta,  the  safest  operation  in  some  cases  will  be 
the  delivery  of  the  foetus  through  a  vaginal  incision,  the  broad 
ligament  being  then  packed  with  gauze.  Donald  reports  a  case 
where  this  was  done  as  late  as  the  seventh  month.  The  abdomen 
had  first  been  opened,  and  the  placenta  found  in  such  a  position 
that  its  removal  was  not  considered  safe. 

Case  of  Tubal  Gestation  with  attempted  Abortion  ;  the  Haematocele 
Sac  containing  Ovarian  Tissue,  and  incorporated  with  the 
Broad  Ligament.     (H.  M.-J.) 

The  tube  and  sac  wall  shown  in  Plate  LXXVL  were  removed 
from  a  lady,  aged  29,  who  had  been  married  for  seven  years  :  a 
nullipara.  Catamenia  had  been  'regular  until  six  weeks  before  the 
operation,  when  she  missed  a  fortnight.  She  was  then  attacked  by 
pain  in  her  right  side.  At  the  end  of  fourteen  days  the  catamenia 
appeared,  and  haemorrhage  continued  until  the  date  of  the  operation. 
The  discharge  was  rather  offensive,  and  veiy  dark  in  colour.  On 
examination  an  adnexal  swelling  was  found  filling  Douglas's  pouch. 
The,  uterus  was  fixed.     Immediate  operation  was  decided  upon. 

At  the  operation  the  haematocele  sac  was  completely  covered  by 
the  broad  ligament,  being  incorporated  with  one  layer  of  the  latter. 
A  clamp  was  applied  on  its  outer  side,  and  the  tubo- ovarian  vessels 
tied  off.     A  clamp  was  next  placed  on  the  uterine  side,  and  the 


l'r-.\Ti:s    LXXVT.    AND    LXXYIT. 


KiGHT  Peeitueal  H^jiatucele  ■with  the  Outer  Sl'kface  of  the  Wall 
OF  THE  8ac.  (Author.) 
The  anterior  wall  was  incorporated  with  the  broad  ligament.  The  window  was 
cut  into  the  ovarian  stroma.  The  distended  tube  is  seen  above,  the  section 
of  which,  for  the  purpose  of  examination,  appears  at  the  inner  pole.  The 
ovary  was  flattened  out  on  the  back  of  the  sac,  and  was  diagnosable  only 
on  section. 


Shows  the  Axteriok  Wall  of  the  Sac  and  Ovarian  Stroma.    (Author.) 

The  entire  hematocele  sac  was  removed  in  the  manner  described  in  the  text. 
The  section  seen  at  the  outer  extremity  of  the  tube  was  made  for  the 
purpose  of  examination.    (See  pp.  710,  711,  for  description  of  the  gestation.) 

[To  face  p.  710. 


EXTBA-UTERINE  PREGNANCY. 


broad  ligament  divided  and  ligatured.  An  effort  was  now  made  to 
peel  oft"  the  sac  wall  and  roiuo\c  it  in  its  entirety,  but  this  was  not 
possible,  and  part  of  it  had  to  be  enucleated  in  pieces.  8ouie  bleed- 
ing vessels  deep  in  the  pelvis  were  ligatured,  the  cut  ligament  united 
by  suture,  and  the  peritoneum  closed  completely.  The  following  is 
the  pathological  report  made  for  me  by  Cuthbert  Lockyer  : — 

On  examination  an  adnexal  swelling  was  found  filling  Douglas's  pouch. 
The  uterus  was  fixed.     Immediate  operation  was  decided  upon. 

The  preparation  consists  of  a  distended  left  fallopian  tube  to  which  is 
attached  along  its  lower  border  part  of  the  wall  of  a  hteniatocele  sac. 

The  above  tube  measures  7  cms.  in  length.  At  its  uterine  end  it  is  normal 
in  size,  but  it  at  once  begins  to  enlarge  gradually  into  a  dark-coloured  cyst 
with  thin  walls. 

The  distended  part  of  the  tube  occupies  the  outer  4  cms.,  and  its  diameter 
measures  8  cms.  The  ostium  abdominale,  owing  to  a  twist  in  the  ampulla 
of  the  tube,  faces  downwards  and  inwards,  instead  of  directly  outwards.  Jt 
is  patent,  sufficiently  so  to  admit  a  crow-quill.  When  the  hematocele  sac 
was  intact  the  ostium  opened  directly  into  it  in  the  usual  manner  of  a  peri- 
tubal hajmatocele. 

The  hfematocele  sac  contains  ovarian  tissue.  The  ovary  has  in  fact  been 
flattened  and  spread  out  on  the  back  of  the  sac,  and  has  become  incorpo- 
rated with  the  adventitious  fibrous  tissue  to  such  an  intimate  degi'ee  as  to  be 
diagnosable  only  upon  section.  A  window  has  been  cut  into  the  ovarian 
stroma,  and  the  tissue,  which  was  removed  from  the  oblong  gap  seen  in  the 
photo,  shows  unruptured  Graafian  follicles,  one  of  which  contains  a  degene- 
rate ovum ;  it  also  shows  the  remains  of  corpora  lutea  and  much  dense 
ovarian  stroma. 

The  blood-clot  which  was  removed  (during  the  operation)  from  the  hsema- 
tocele  sac  weighed  half  an  ounce  after  hardening.  It  contains  no  chorionic 
villi.  The  dark  thin-walled  tubal  swelling  has  been  cut  through  at  its 
uterine  and  at  its  ampuUary  extremities.  Discs  of  tissue,  including  the 
entire  transverse  section  of  the  tube  at  these  two  levels,  show  that  the  lumen 
is  occupied  by  blood-clot,  which  contains  degenerate  fibrolic  chorionic  villi. 
No  decidual  tissue  is  apparent.  The  plicae  are  much  flattened  out,  but  they 
are  covered  by  intact  cubical  epithelium. 

The  amount  of  lisemorrhage  has  been  too  free  to  show  any  sign  of  a  capsu- 
laris  around  the  implantation  of  the  ovum. 

Diagnosis. — This  is  obviously  a  case  of  primary  tubal  gestation  with 
attempted  abortion.  Xone  of  the  gestation  products  escaped  through  the 
ostium,  but  the  haemorrhage  therefrom  was  gradual  enough  to  allow  of  the 
formation  of  a  peritubal  hsematocele.  At  the  time  of  removal,  the  gestation 
products  in  the  tube  were  reduced  to  a  carneous  molar  formation,  with  total 
suppression  of  the  amniotic  sac. 

Plate  LXXVII.  shows  the  tube  and  posterior  wall  of  the  sac ;  the  anterior 
wall  was  so  incorporate  with  the  posterior  layer  of  the  left  broad  ligament 
that  it  covdd  not  be  removed  entire,  and  is,  therefore,  not  represented. 


712  DISEASES   OF   WOMEN. 

A  case  of  Cullingworth's  illustrates  the  difficulties  of  diagnosis 
and  treatment.  The  mass  in  the  pouch  of  Douglas  was  first  mis- 
taken for  retroversion  of  the  uterus — an  error  which  Cullingworth 
cleared  up  by  use  of  the  sound.  The  uterus  and  appendages  and 
the  gestation  were  removed  by  abdominal  section.  The  Fallopian 
tubes  were  found  normal,  though  the  ostia  were  closed  and  adhering 
to  the  ovaries ;  the  gestation  was  complicated  by  the  presence  of 
several  subserous  myomata ;  the  sac  was  covered  for  one-fourth  of 
its  entire  circumference  by  uterine  tissue,  and  a  short  distance  from 
it  the  Fallopian  tube  was  occluded ;  the  umhilical  cord  lay  entirely 
ivitJiin  the  sac,  and  there  was  no  indication  of  a  placenta.  The 
conclusion  of  Cullingworth  that  the  gestation  was  originally  tubo- 
ovarian  appears  to  be  the  most  correct. 

When  an  ectopic  gestation  is  first  detected  at  or  after  mid-term, 
some  authors  advise  that  it  be  left  till  term,  in  order  not  to  sacrifice 
the  child.  Others  advise  waiting  still  longer,  until  the  child  is  dead, 
and  the  placental  circulation  has  ceased.  The  second  argument,  of 
course,  nullifies  the  first.  It  is  probably  better  to  operate  at  mid- 
term, or  as  soon  as  the  condition  is  discovered.  There  is  no  record, 
so  far  as  I  know,  of  a  tubal  child  attaining  to  adult  life.  More- 
over, the  earlier  the  operation  is  undertaken,  the  easier  it  is,  and 
the  safer  for  the  mother.  This  last  consideration  should  also  be 
the  first. 

In  operations  during  the  latter  half  of  pregnancy,  the  question 
of  greatest  importance  is  what  to  do  with  the  placenta.  It  was 
formerly  taught  that  no  attempt  should  be  made  to  separate  the 
placenta  when  the  child  is  living.  But  Taylor's  valuable  recent 
observations  have  placed  the  matter  in  a  difierent  light,  and  given 
important  practical  rules  for  treatment  by  the  distinction  he  has 
drawn  between  true  tubo-abdominal  pregnancy,  in  which  the 
placenta  is  more  or  less  connected -with  the  Fallopian  tube,  and 
the  rarer  form  in  which  there  has  been  a  late  rupture  of  a  broad- 
ligament  pregnancy,  where,  consequently,  the  child  is  in  the  abdomen, 
and  the  placenta  is  intra-ligamentary.  Broadly,  when  it  has  a  tubal 
attachment,  the  placenta  should  be  removed;  when  it  is  intra- 
ligamentary,  it  should  be  left.  Mayo  Robson  has  recorded  a  case  in 
which  he  found  it  easy  to  remove  a  placenta  at  term ;  it  was  a  true 
tubo-abdominal  pregnancy.  Van  Both  has  recorded  a  similar  case 
operated  on  during  the  eighth  month  ;  the  child  survived  twenty 
hours.  He  says  that  whether  it  had  developed  intra-ligamentarily 
or  not  could  not  be  ascertained,  but  it  is  probable  that  it  had  so 


EXTRA-rTEUTXE   PUEGNANCY.  713 


developed,  because  'after  separation  of  adhesions,  the  placenta  was 
found  to  possess  a  pedicle  which  was  ligatured,  and  the  whole 
placeuta  was  removed.' 

When  the  placenta  is  in  such  a  position  that  it  cannot  be 
removed,  the  margins  of  the  sac  should,  if  possible,  be  sewn  to 
the  peritoneal  edges,  and  the  sac  itself  packed  with  iodoform  gauze.* 
The  placenta  gradually  disintegrates  and  separates ;  there  is  some 
risk  of  septicfeiuia,  and  convalescence,  at  the  best,  is  apt  to  be 
tedious. 

Thorne  of  ^lagdeburg,  after  observation  of  a  hundred  and  thirty-six  cases 
of  tubal  pregnancy,  a  hundred  and  thirty-two  of  which  occurred  in  the  first 
three  months,  and  tliirty  of  which  were  operated  upon  by  laparotomy,  and 
nine  by  vaginal  incision,  arrives  at  these  conclusions  :  that  every  case  of 
ectopic  pregnancy,  or  its  results,  should  be  placed  as  soon  as  possible  under 
clinical  care.  Every  ectopic  ovum  should  be  removed  by  laparotomy  if 
living,  or  even  though  dead,  if  still  in  its  ovisac,  as  soon  as  the  second 
month  of  pregnancy  has  elapsed ;  an  ovum  of  not  more  than  eight  weeks' 
development  can  be  conipletelj'  resorbed  in  the  tube  without  subsequent  01 
effect,  but  this  can  only  happen  under  firm  clinical  control.  Threatening 
symptoms  of  decomposition  or  secondary  hgemoiThage  appear  to  indicate 
extirpation;  rupture  and  haemoiThage  into  the  abdominal  cavity  call  for 
immediate  laparotomy;  if  the  hsemorrhage  cease,  and  if  a  circumspect 
examination  does  not  discover  any  tumour  in  the  uterine  region,  we  should 
wait.  Eecent  hsematocele  is  not  to  be  operated  on ;  a  rise  of  temperature  in 
the  first  week  does  not  point  to  decomposition ;  nor  should  one  proceed  to 
operation  because  of  resoi-ption  not  taking  place,  imtil  six  weeks  at  least  have 
elapsed. 

Bouilly  of  Paris,  from  the  conduct  of  fifty  cases,  maintains  that  the  general 
surgical  rule  may  be  laid  down  that  extra-uterine  pregnancy  in  the  course 
of  evolution,  or  arrested  in  its  evolution,  imperiously  demands  operative 
interference,  and  that  the  operation  to  be  done  is  salpingectomy — removal 
of  the  ruptured  tube. 

Feliling  argues  that  operation  is  indicated,  if  in  spite  of  rest  under  medical 
observation  the  tumour  continues  to  get  larger,  if  there  be  symptoms  of 
internal  haemorrhage,  or  suppuration  of  the  sac.  He  advocates  the  removal 
of  diseased  aduexa  by  the  abdominal  method. 

At  the  Congress  of  the  German  Gynaecological  Society  at  Wurzburg,  June 
1903,  the  treatment  of  extra -uterine  pregnancy  was  summarized  by  Yeit  as 
follows :  "When  an  ectopic  foetus  is  alive  operation  is  always  indicated,  and  in 
most  cases  extirpation  of  the  sac ;  the  abdominal  route  is  to  be  preferred, 
though  in  the  early  stage  of  pregnancy  good  results  are  obtained  by  the 
vaginal  way.  Operation  is  also  indicated  when  the  embrj'o  is  dead  in  the 
early  period,  while  it  is  still  in  the  sac  ;  when  it  has  been  ejected,  one  should 
wait,  and  not  operate  unless  new  symptoms  supervene.    In  that  case  the  sac 

*  See  note,  p  717- 


714  BISUA.'^ES   OF    WOMEN. 

should,  if  possible,  be  extirpated.  When  the  sac  has  ruptured  into  the 
abdominal  cavity  and  the  woman's  life  is  endangered,  interference  must  at 
once  be  undertaken ;  when  her  general  condition  is  tolerable  one  may 
wait. 

When,  in  the  later  period,  the  fostus  is  dead,  one  should,  if  the  general  con- 
dition be  critical,  extirpate  the  sac.  In  the  presence  of  suppuration  of  the 
sac,  operation  is  imperative  and  drainage  is  then  indicated.  In  some  favour- 
able cases  the  sac  may  be  extirpated  even  when  there  are  no  symptoms. 

In  regard  to  the  technique  of  these  operations,  an  important  fact  to  re- 
member is  that  every  foetal  sac  has  a  pedicle,  and  that  the  bleeding  can  be 
controlled  by  ligature  of  the  afferent  bloodvessels — generally  the  ovarian 
and  uterine  arteries. 

Herman  *  is  strongly  in  favour  of  removal  of  the  extra-uterine  pregnancy 
and  its  sac  when  favourably  situated,  and  shows  how  experience  is  tending  to 
disparage  expectant  treatment  with  its  accidents,  uncertainty,  and  long-drawn- 
out  anxiety  and  miser^^  especially  in  the  first  half  of  pregnancy.  '  If  an  extra- 
uterine pregnancy  be  found  befoi'e  rupture  or  haemorrhage  has  occurred,  it 
should  be  removed.  This  operation  is  a  simple  removal  of  a  tube  under  the 
best  conditions,  and  its  risks  are  as  nothing  compared  with  the  risks  of 
allowing  the  condition  to  take  its  course.' 

When  rupture  has  occurred  with  hgemorrhage,  or  if  there  be  intra-peritoneal 
bleeding,  operation  is  indicated.  It  may  be  justifiable  to  temporize  until  a 
patient  can  be  removed  to  a  more  suitable  place  for  operation.  The  same 
rule  applies  to  tubal  mole  and  incomplete  abortion.  Pelvic  haematocele  has 
already  been  dealt  with  (see  Pelvic  Haamorrhage).  Whether  the  abdominal 
or  the  vaginal  route  be  followed  will  depend  on  the  conditions  existing  in 
the  individual  case,  the  size  and  the  position  of  the  mass,  and  the  nature  of  the 
haBmorrhage.  An  operator  who  is  not  experienced  in  vaginal  methods  will 
find  the  abdominal  route  afford  greater  facilities  in  the  removal  of  the 
gestation  sac  and  in  the  securing  of  vessels  ;  also  the  prospect  is  avoided  of 
having  to  open  the  abdomen  when  the  effort  by  the  vagina  has  failed. 

Herman  recommends  waiting  until  the  foetus  is  dead  and  the  placenta 
thrombosed,  when  the  foetus  may  be  removed  and  the  placenta  peeled 
off  without  bleeding.  Onset  of  fever  and  signs  of  pus  are  certain  indications 
for  interference  to  prevent  the  patient  being  worn  down  by  exhaustive 
suppuration.  If  the  pregnancy  be  abdQminal,  the  route  of  attack  is  ab- 
dominal, but  if  the  iwegnancy  be  in  the  broad  ligament  posteriorly,  and 
prominent  in  the  vagina,  the  foetus  rpay  be  removed  vaginally,  and  the 
drainage  of  the  placenta  carried  out  this  way.  Taylor  has  shown  distinctly 
that  in  some  cases  the  placenta  is  located  almost  entirely  upon  the  tubal  wall, 
which, however,  may  be  pulled  and  curled  in  very  complicated  ways;  in  these 
cases  of  true  tubo-abdominal  pregnane}^  he  advises  that  the  placenta  should 
be  removed  at  term,  since  the  bleeding  is  almost  entirely  controlled  when  the 
uterine  and  ovarian  vessels  are  tied. 

The   surgeon  will,  however,  judge  each  case  on  its  merits,  and 

^  Brit.  Mnd.  Jour.,  Jan.  9,  190^. 


PLATE   LXXVIIT. 


Gestation  Sac  wltu  Fcetus;  the  Upper  Cavity  shown  in  the  Drawing 

IS    THAT    IN   WHICH    THE    SePTIC    FlTjID    WAS    CONTAINED.      (AUTHOE.) 

Tubal  gestation,  ending  in  molar  pregnancy,  with  secondary  suppuration,  the 
formation  of  a  septic  sac.     (H.  M.-J.) 

Report  by  Mr.  Targett :  "  On  section  the  wall  of  the  gestation  sac  was  found  to 
be  infiltrated  with  blood-clot  and  fibrin,  as  in  a  tubal  mole.  "Where  sup- 
puration has  occurred  the  placental  tissue  is  separated  from  the  inflamed 
tube  by  pus,  and  chorionic  villi  are  in  actual  contact  with  inflammatory 
products.  The  mucous  membrane  of  the  tube  is  destroyed  and  replaced  by 
granulation  tissue.  The  tumour  is  roughly  spherical  in  shape  and  measures 
8x7x6  centimetres  (o\  X  2|  x  2^  inches)  in  its  chief  diameters  after 
fixation  in  formalin.  A  portion  of  the  posterior  wall  of  the  mass  has  been 
removed  and  reveals  two  cavities.  The  larger  of  these  is  the  gestation  sac 
containing  a  foetus,  while  the  smaller  is  a  space  formed  between  tlie  gesta- 
tion sac  and  the  wall  of  the  dilated  FalloiDian  tube.  In  the  recent  state 
this  latter  space  was  filled  with  very  offensive  pus.  Flattened  out  on  the 
half  of  the  tumour  nearest  to  the  uterus  is  the  right  ovary.  The  characters 
of  the  gestation  sac  are  precisely  those  of  an  apoplectic  or  blighted  ovum. 
It  measures  about  five  centimetres  in  its  chief  diameter,  and  its  wall  is 
composed  largely  of  blood-clot  in  various  stages  of  consolidation.  The 
interior  is  lined  with  amnion,  which  is  unevenly  raised  by  haemorrhages 
beneath  it.  A  fcetus  measuring  2-75  centimetres  is  attached  to  the  wall  of 
the  sac  by  an  CBdematous  umbilical  cord  TTS  centimetres  in  length,  corre- 
sponding with  the  stage  of  development  at  the  end  of  the  second  month. 
The  suppurating  cavity,  semilunar  in  shape,  represents  that  part  of  the 
dilated  amjralla  of  the  tube  not  occupied  by  the  gestation  sac.  From  this 
relation  it  would  appear  that  the  tubal  gestation  had  ended  in  a  molar 
pregnancy  or  apoplectic  ovum,  and  that  secondary  suppuration  had  been 
set  up  within  the  dilated  tube  and  around  the  ovum.  Consequently  the 
pus  had  collected  in  that  internal  cavity  which  always  surroimds  a  tubal 
mole  owing  to  the  ovum  being  adherent  at  only  one  spot  upon  the  wall  of 
the  dilated  tube.'  [To  face  p.  715. 


EXTnA-UTERTNE  PREONAXCY.  715 


act  in   accordance   with  his  anatomical   knowledge    and    operative 
experience. 

Some  of  the  practical  difficulties  of  dealing  with  ectopic  gestation 
will  be  better  realized  from  reading  the  following  cases  : — 


Ectopic  Gestation  Sac  complicated  with  a  Septic  Abscess  Cavity 
in  the  Sac.     (H.  M.-J.)     (Plate  LXXVIII.j 

A  patient,  aged  30.  married  nine  years,  had  one  pregnancy  at  the  close  of 
the  first  year.  The  periods  had  been  normal  and  regular  up  to  four  months 
before  operation.  About  this  time  the  first  attack  of  violent  abdominal  pain 
occurred.  There  were  recurrences  of  the  pain  later  on,  associated  with 
hemorrhage,  and  the  discharge  of  some  material  '  like  the  roe  of  a  mackerel ' 
from  the  uteras.  On  examination,  there  was  found  a  fairly  large  tumour 
behind  the  uterus  and  associated  with  it,  the  uterine  cavity  being  some  two 
and  three-quarter  inches  in  length.  Abdominal  cceliotomy  was  detennined 
upon.  The  adhesions  were  separated  with  but  little  trouble,  but  in  the 
delivery  of  the  sac  through  the  enlarged  abdominal  incision  a  portion  of  the 
thin  wall  ruptured  and  some  extremely  fcetid  fluid  escaped,  creating  quite 
a  stench.  The  pelvic  cavity  was  repeatedly  cleansed  with  formalin  solution, 
and  as  the  bowel  was  well  protected  from  the  sac,  the  only  parts  really 
affected,  and  this  was  unavoidable,  were  the  margins  of  the  wound.  These 
latter  were  well  wiped  with  fonnalin  solution  before  being  closed,  and  an 
iodoform  gauze  drain  was  left  in.  The  patient  did  not  progress  favourably, 
there  was  great  difficulty  with  the  bowel,  and  tympanitis  and  vomiting 
gradually  set  in.  On  the  fourth  day  I  reopened  the  abdomen.  On  doing 
so  I  found  the  atonic  bowel  to  be  considerably  distended,  but  could  not 
detect  any  kink  or  cause  for  obstruction.  The  pelvic  cavity  was  quite 
free  from  any  fluid,  and  there  was  no  evidence  of  any  peritonitis  or  of 
infection  of  the  peritoneum,  but  the  margins  of  the  abdominal  wound  showed 
a  dense  slough  for  its  entire  extent.  There  had  been  no  indication  of  this 
from  the  appearance  of  the  incision.  The  patient  had  complained  of  littie  or 
no  pain  from  the  time  of  the  operation.  The  slough  at  either  side  was  cleared 
off  as  far  as  possible,  and  a  drainage  tube  was  inserted.  The  temperature  fell 
the  next  day  to  normal,  but  again  it  rose  to  100"  in  the  evening,  the  pulse 
becoming  more  rapid  (from  120  to  140),  with  a  return  of  the  vomiting. 
Despite  every  means  employed  to  combat  the  sickness  and  maintain  her 
strength,  including  enemata,  saline  injections,  washing  out  of  the  stomach, 
etc.,  death  occun-ed  on  the  seventh  day  after  operation. 

It  woidd  seem  that  the  source  of  infection  of  the  sac  must  have  been  through 
the  adlierent  bowel.  The  patient  having  suffered  from  retroversion  of  the 
uterus,  the  early  symptoms  might  naturally  lead  to  the  impression  that  it  was 
an  erdarged  retroverted  and  gravid  uterus,  and  tend  to  make  the  diagnosis  less 
certain.  From  the  size  of  the  tumour  and  the  impression  which  it  conveyed 
of  fixation  by  adhesions,  I  determined  on  the  abdominal  operation,  though, 
as  events  proved,  considering  the  nature  of  the  sac,  the  vaginal  one  would 


716  DISEASES   OF   WOMEN. 

have  been  the  safest  one  for  the  patient.  Had  I  a  similar  case  again,  with 
rupture  of  a  foetid  sac,  having  protected  the  bowel,  I  should  first  char  the 
margins  of  the  abdominal  wound  with  the  thermo-cautery,  and  then,  at  some 
distance  from  the  charred  surfaces,  make  a  new  incision  at  either  side  before 
closing  the  wound. 

In  another  case  I  opened  the  abdomen  for  a  large  and  very  fcetid  sub- 
peritoneal abscess  which  had  penetrated  the  peritoneum.  Having  evacuated 
the  pus  and  thoroughly  cleansed  out  the  abdominal  cavity  with  formalin, 
disinfecting  the  edges  of  the  wound,  which  were  covered  by  a  foul  deep  slough, 
I  removed  this  at  either  side  before  bringing  the  edges  together  and  drained. 
Contrary  to  my  expectation,  the  patient  made  an  excellent  recovery. 

The  following  case  show-s  the  vital  importance  of  early  diagnosis, 
and  the  fatal  consequence  of  operative  delay  when  rupture  of  the 
ectopic  sac  has  occurred. 

Case  of  Ectopic  Gestation  with  Escape  of  Gestation  Sac  into 
the  Peritoneal  Cavity."'    (H.  M.-J.)     (Plate  LXXIX.) 

The  patient,  eet.  33,  had  been  married  for  upwards  of  four  years  ;  there 
had  been  no  previous  conception.  A  year  previously  she  had  been  treated 
for  an  erosion  of  the  cervix.  .  The  last  menstrual  period  occurred  eleven  weeks 
before  the  onset  of  her  illness,  which  was  on  July  10th,  when  she  was  seized 
with  acute  pain  in  the  abdomen,  and  sickness,  the  consequences,  as  she 
thought,  of  a  chill  taken  the  same  day.  The  pain  was  relieved  by  rest  and 
sedatives,  recurring,  however,  periodically.  As  ectopic  gestation  was  feared, 
she  was  kept  in  bed  and  under  observation.  On  the  15th  there  was  a  recur- 
rence of  the  symptoms,  followed  by  greater  prostration,  but  no  uterine 
haemorrhage.  Again  she  appeared  to  get  better,  but  on  the  24th  violent 
abdominal  pains  set  in,  the  pulse  became  very  rapid,  and  the  face  blanched  ; 
she  was  seen  for  the  first  time,  in  this  condition.  The  abdomen  was  tumid 
and  dull  on  percussion,  the  uterus  fixed,  and  the  pouch  of  Douglas  occupied 
by  a  resistant  swelling.  At  the  time  of  operation  the  pulse  was  weak  and 
fluttering,  and  the  lips  quite  blanched. 

On  opening  the  abdomen  the  cavity  was  found  filled  with  blood.  This, 
with  masses  of  soft  coagula,  was  removed.  The  gestation  sac  was  at  once 
discovered  about  the  level  of  the  umbilicus,  Avith  the  placenta,  the  mass  being 
adherent  to  the  bowel  (see  Plate  LXXIX.).  It  bled  freely.  Tlie  haemorrhage 
was  controlled  digitally,  and  still  blood  welled  up  in  quantity  from  the 
pelvis.  The  bleeding  was  proceeding  from  a  large  rent  in  the  left  broad 
ligament,  running  close  up  to  the  uterus.  This  was  quickly  stopped  by  the 
application  of  two  long  Doyen's  clamps  running  at  either  side  of  the  rent. 
The  gestation  mass  was  then  removed,  the  adhesions  being  separated,  and 
any  bleeding  points  ligatured.  Ligatures  were  then  passed  at  either  side  of 
the  clamps  with  Deschamp's  needles,  and  the  broad  ligament  secured.  Up 
to  this  nothing  was  seen  of  the  foetus,  and  ultimately  it  was  found  under  the 

*  Brit.  Gyn.  Jour.,  Feb.  1902, 


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liXTUA-  UTEIUNK,  1  L'UEd  NANCY.  Ill 

diai)liragni,  in  the  left  hypochondrium.  There  was  no  further  bleeding  and 
the  abdomen  was  closed.  Saline  submammary  injections  had  been  adminis- 
tered during-  the  latter  part  of  the  operation,  and  were  continued  throughout 
the  day,  with  stimulating  rectal  cnemata.  She  rallied  for  some  hours  after 
tlie  operation,  but  never  recovered  from  the  collapse,  surviving  only  nineteen 
hours.  Her  surroundings  were  not  the  most  proi)itious  for  recovery,  though 
her  medical  attendant  left  nothini;:  iindone  to  secure  it. 


Note  on  Iodoform. 

There  have  been  several  instances  of  toxic  effects  of  iodoform  in  pelvic  and 
abdoudnal  operations.  So  mucli  so  that  it  is  a  quesliun  if  it  be  not  better  to 
abandon  iodoform  as  a  post-operative  dressing  or  pack.  I  have  reported  some 
cases  of  this  nature  and  one  remarkable  one  in  which  a  pemphigus  and  eczcma- 
tous  eruption  followed  the  use  of  iodoform  gauze.  I  am  gradually  abandoning 
tlie  latter  for  simple  sterilized  or  chinusol  gauze.     (Autuor.) 


CHAPTER  XXXVI I. 


AFFECTIONS  OF  THE  OVARIES— OVARITIS. 

We  may  thus  classify  the  affections  of  the  ovaries,  apart  from  the 
Fallopian  tubes  : — 


Foreign  bodies. 

Abnormalities 

,,  absence. 

„  imperfect      deve- 

lopment. 
Displacements. 

Hernia. 

Prolapse. 

Ovaritis. 

„         non-cystic   f  acute  and 
„  cystic  \      chronic. 

Sclerosis  and  Cirrhosis. 

Teratoma. 


Solid  tumours. 
Tubercle. 
Fibroma. 
Myoma. 
Sarcoma. 
Carcinoma. 
Endothelioma. 
Gyroma 

Cystoma. 

Simple. 

Adenoma. 

Dermoid. 

Papilloma. 

Colloid. 

Racemose. 


Ovarian  Development  and  Osteomalacia. 

Pestalozza  has  drawn  special  attention  to  the  correlation  that  exists  between 
deficient  development  of  the  ovaries  and  the  occurrence  of  osteomalacia. 
Such  abnormality  in  the  ovary  need  not  necessarily  interfere  with  menstru- 
ation or  conception.  The  deficient  development  of  the  corpus  luteum  is  a 
factor  in  the  atrophy  of  the  ovary.* 

Foreign  Body  in  the  Ovary.^Frank  W.  HavUand  reported  a  case  where 
he  removed  an  extensively  adherent  pus  tube  and  ovary.  The  adhesion 
involved  the  sigmoid  flexure  of  the  colon,  the  tube,  ovary,  uterus,  and 
omentum,  in  a  large  mass.  On  examining  the  ovary  an  abscess  was  found, 
inside  which  a  needle  was  discovered.  The  appearance  of  the  needle  (about 
three-quarters  of  an  inch  of  an  ordinary  sewing  one)  proved  it  to  have 


*  Tuscan.  Oha.  and  Gyn.  Soc,  and  Bull.  d.  Soc,  Jan.  4,  1903. 


PLATE   LXXX. 


Section  of  Cystic  Ovaritis  of  Ovaky,  Sclerotic  and  Cystic  Degenera- 
tion, WITH  Thickened  Fallopian  Tube:  Fimbria  Normal.    (Author.) 

PLATE   LXXXL 


Section  of  Htdrocystic  ant)  Sclerosed  Ovary.  Adhesions  on  the  En- 
larged Fallopian  Tube  and  Accessory  Ostia  with  Small  Peduncu- 
lated Cyst  of  Morgagni  (o).  [To  face  p.  718. 


PLATE    LXXXII. 


Ovaries,  showing  ix  the  Eight  a  Cyst  with  Coaguluji  ;   in  the  Left, 
Old  and  Recent  Coepoka  Lutea. 


PLATE   LXXXIIL 


liiLOCLLAE  Cystic  Ovaky  with  Fallopian  Tube. 

[To  face  i^.  719. 


AFF£CTIO^^S  OF  THJS   OVAlUES—OVAllJirs.  710 

rested  there  some  time.  The  explanation  of  its  presence  was  as  follows  : 
That  it  was  swallowed  and  passed  through  the  alimentary  canal  until  it 
reached  the  colon,  when  it  perforated  the  walls,  passed  on  through  a  fold 
of  omentum  into  the  peritoneal  covering  of  the  posterior  wall  of  the  nterus, 
and  thence  on  into  the  right  ovary,  carrying  with  it  infection  from  the 
alimentarj'  canal. 

Abnormalities — Displacements  of  the  Ovary. 

Absence  of  the  Ovaries. — Cases  of  absence  of  the  ovaries  are 
recorded  elsewhere  in  this  work  (pp.  42,  176,  808;  and  chapters  on 
the  Vagina  and  A'ulva). 

Hernia  of  the  Ovary. — This  is  a  rare  affection.  It  is  usually 
congenital  and  double,  but  its  accidental  occurrence  as  the  result 
of  strain  or  injury  is  not  to  be  overlooked.  Hernia  of  the  ovary 
is  generally  associated  with  some  congenital  malformation  of  the 
genital  organs,  either  uterus  or  vagina,  or  both. 

Diagnosis. — A  swelling  is  found  in  the  inguinal  region  about  the 
size  of  a  walnut,  which  on  coughing  may  protrude  into  the  inguinal 
canal.  In  drawing  the  uterus  down  with  a  hook  or  vulsellum,  the 
tumour  is  dragged  on  and  pulled  with  the  uterus. 

An  interesting  case  of  double  hernia  of  the  ovary,  with  congenital  malforma- 
tion of  the  uterus  and  vagina,  was  brought  before  the  Gynaecological  Society. 
Hulke  removed  one  ovary,  and  Heywood  Smith  the  other.* 

Should  the  ovary  be  painful,  w^ith  associated  menstrual  and  reflex 
troubles,  the  best  course  to  pursue  is  to  remove  it.  If  the  patient 
objects  to  this,  a  hollow  shield  may  be  worn. 

Prolapsus. 

Varieties  (Munde)  : 
Retro-lateral. 
Retro-uterine. 
Ante-uterine. 
In  the  infundibulum  of  an  inverted  uterus. 

Causes : 

Pregnancy  and  parturition. 

Pelvic  tumours. 

Uterine  displacements. 

Enlargement  of  the  ovary  from  any  cause. 

Adhesions. 

Sudden  jolts,  etc. 

*  Brit.  Gijn.  Jour. 


720  DISEASES   OF    WOMEN. 

Diag'nosis. — On  examination  by  the  vagina  and  rectum,  the  sensi- 
tive ovary  is  felt  in  its  altered  position. 

Treatment. — A  displaced  ovary  is  often  a  diseased  ovary,  and  not 
infrequently  associated  with  other  pelvic  abnormalities.  The 
commonest  complication  is  a  uterine  retro-displacement.  This  latter 
complication  should  be  rectified,  when  possibly  the  ovary  will  at  the 
same  time  be  raised  from  its  abnormal  position.  If  palliative  treat- 
ment be  determined  upon,  an  effort  must  be  made  to  support  the 
sensitive  ovary  with  a  glycerine  pad  or  air  pessary,  and  coitus  must 
be  avoided.  The  hot  iodized  or  Woodhall  vaginal  douche  should  be 
used,  and  the  bed  on  which  the  patient  sleeps  raised  at  the  foot. 
Any  displacement  must  be  rectified,  and  the  knee  elbow  position 
assumed  several  times  daily.     The  rectum  must  be  kept  empty. 

Rose  *  records  cases  in  which  the  ovary  was  attached  to  the  psoas 
muscle  by  a  peritoneal  fold,  and  another  of  strangulation  of  the  ovary 
at  the  internal  inguinal  ring. 

Posterior  Colpotomy. — The  prolapsed  ovary  may  have  to  be 
removed  by  drawing  it  down  with  an  ovum  forceps  through  an 
incision  in  the  posterior  vaginal  wall,  ligaturing  and  cutting  off  by 
scissors,  if  need  be  leaving  the  incision  open  for  drainage,  f 

Ovaritis. 

Etiology,  Causation,  and  Patholog'y. — Ovaritis  is  generally  asso- 
ciated with  perimetric  inflammations,  as  it  is  most  frequently  met 
with  either  as  a  complication  or  extension  of  these  affections.  '  We 
believe,'  says  Emmet,  '  that  the  ovaries  suffer  far  more  from  peri- 
tonitis or  cellulitis  in  their  vicinity  than  from  disease  originating 
within  or  confined  to  their  own  structure.'  Still,  it  is  doubtful 
whether  inflammation  of  the  pelvic  peritoneum  does  not  more 
frequently  originate  in  the  ovary  (Aran)  or  Fallopian  tube  than  the 
converse.  The  ovary  is  more  or  less  involved  in  every  severe  case 
of  perimetritis.  On  the  other  hand,  metritic  and  endometritic  con- 
ditions may  arise  as  secondary  results  of  both  acute  and  chronic 
ovarian  hypersemia  and  inflammation. 

Active  hyperasmia  of  the  ovary,  however,  maj^  persist  for  a  length 
of  time  without  further  consequences  than  hypertrophy  of  the  con- 
nective tissue  elements  and  interstitial  thickening  of  the  stroma. 
This  hypersemia  leads  to  areolar  thickening,  and  this  to  pressure  on, 

*  Semaine  Medical,  1902,  p.  56.  " 

t  The  operation  of  posterior  colpotomy  is  described,  p.  789. 


PLATE   LXXXIV. 


Sectiux  of  Ovary,  showixg  Advanced  Stage  of  Sclerosis,      x  5. 

portion  magnified  (see  Plate  LXXXV.).  ^Macroscopieally  the  ovary  cut  with 
a  fleshy  appearance  and  without  showing  any  cystic  cavities,  the  cortex 
ha\'ing  a  fibrous  feeh  Under  a  higli  power  the  section  presents  a  general 
fibrous  appearance,  the  corpora  lutea  and  follicles  are  obliterated,  some 
very  small  cavities,  the  contracted  remains  of  cysts  are  scattered  here  and 
there  throughout  the  fibrous  material  and  connective  tissue  elements- 
Some  few  bloodvessels  are  seen  with  hypertrophied  walls  (see  over  page). 
One  small  cyst  cavity  denuded  of  epithelium  is  present.  In  this  case  the 
Fallopian  tube  was  adherent  to  this  ovary,  and  the  parenchymatous  changes 
in  its  walls  obliterated  the  lumen  of  the  tube.  [To  face  p.  720. 


PLATE   LXXXV. 


Section  feom  Ovary  (Plate  LXXXIV.),  showing  Fibeohs  Formation  and 
Minute  Cyst  Cavities;  a  Thickened  Vessel  is  seen  in  the  Field 
near  the  margin. 

[_TofaGe  29.  721. 


AFFECTIONS   OF   THE   OVARIES— OVARITIS. 


721 


and  obliteration  of,  the  follicles,  thus  causing  further  cicatrization 
of  the  connective  tissue,  and,  ultimately,  a  ciiThotic  state  of  the 
organ.  In  the  thickening  of  the  peripheral  layers  of  the  stroma  we 
have  a  satisfactory  explanation  of  the  accompanying  sterility,  for  the 
ripened  ovum  cannot  escape.  Abscess  and  cystic  degeneration  are 
the  occasional  results  of  either  acute  inflammation  or  prolonged  con- 
gestion. Cysts  form  from  the  extravasation  of  blood,  and  the 
degeneration  and  absorption  of  the  coagulum. 

The    following    is    Petits    classification     of     ovaritis    and    its 
complications  : — 


O  var  itis  — ^on-c  vstic 


Ovaritis  — Cystic 


Acute 


Chronic 


,'  Cortical. 

Interstitial. 

Parenchymatous, 
r  Cortical  CHypertrophic. 

\  Disseminated     I  Atrophic. 


(Dropsv  of  the  follicles. 
Ui)  Hydro-cysts  ,  -p.        "     ^  , ,       , 
^  '       "^  •'        [Dropsy  ot  the  stroma. 


(6)  Htemato- 
cysts 


(c)  Pyo-cyst. 


Multiple  and  small 


Follicular 

In  corpora 

lutea. 
In  stroma — 

In  both. 


I    Due       to      inf( 
I        tion. 


Larger  and  fesver  in  j   Due  to  perimetric 
number  I        inflammation. 


Cortical  Ovaritis. 


Bonnet  and  Petit  *  describe  the  ovaritis  of  cortical  origin  as  secondary  to 
inflammation  around  the  ovary,  commonly  caused  by  gonon-hoea.  In  it  the 
serous  covering  of  the  ovary  is  afiected.  It  is  enlarged,  and  its  capsule  is 
thickened.  Diffuse  interstitial  ovaritis  is  due  to  puerperal  infection;  the 
ovary  is  largely  increased  in  size  and  engorged  with  fluid,  whfle  the  cystic 
follicles  have  either  serous  or  sanguineous  contents,  the  stroma  being  the 
seat  of  a  diffuse  embryonic  infiltration.  Later  on  pus  appears  in  the  lymph 
spaces  or  the  follicle.  Parenchymatous  ovaritis  is  due  to  infectious  diseases. 
The  lesions  are  concentrated  in  the  corpora  lutea,  or  the  piimordial  foUicle  is 
exclusively  attacked  or  completely  disappears. 

It  is  interesting  to  note  the  view  of  Baere,  recently  supported  by  Clark. 


*  lAb.  cit.  for  this  pathological  sammary. 


3  A 


-^"t^- 


Fig.  485. — Chro:nic  Coutical  Ovaritis.     (  x  30  diameters.) 
(Bonnet  and  Petit.) 

A,  A,  Sclerosis  of  albugir.eoiis  layer  ;  B,  b,  follicular  cysts ;  c,  c,  corpora  lutea 
degenerating;  d,  d,  the  same,  separated  by  ha3morrhagic  infarctions;  d, 
corpus  luteum  changed  into  a  small  hajmorrhagic  cyst;  e,  e,  interstitial 
hajmorrhages ;  f,  interstitial  tissue  in  process  of  sclerosis.  Compare  with 
Normal  Section,  Fig.  48fj. 


r. 


5^%^^^5K'T2££;225:3''?»»n*^ 


'{!■£.. 


FiG:  486. — Section  of  Normal  Ovary,     (x  30  Diameters.)    (Maoalister.*) 
e.  Fine  connective  tunica  alhnginea ;  s,  spindle-celled  layer  of  the  zona  paren- 
chymatosa  or  stroma ;  1,  2,  3,  Graafian  follicles,  the  largest  of  which  are 
internal,  but  grow  towards  the  surface.     See  also  Fig.  488. 

*  'Each  Graafian  follicle  consists  of  (1)  a  tunica  fibrosa,  or  the  differentiated 


PLATE   LXXXVI. 


Macroscopical  Appkakaxck  of  an  GEdematous  and  Sclerosed  Ovary,  with 

Thickened  Capsule  and  some  Small  Cystic  Cavities  in  the  Cortex. 
The  vessels  were  in  most  part  obliterated.     There  was  a  blood  cyst  at  one  i^ole. 

The  ovary  was  one  removed  for  persistent  ovarian  dyemenorrhcea. 

other  ovary  was  resected. 


The 


PLATE   LXXXVII. 


PLATE   LXXXVIII. 


Macroscopical  Appearances  of  Sclerosed  and  I'ystic  Ovaries,  with 
Nodular  Salpingitis. 

Removed  from  a  patiiut.  who  had  suffered  for  years  from  violent  aduesal  pain, 
dysmenorrhcea,  and  recently  from  meuorrhagia,  with  symptoms  of  disordered 
meutalization  during  the  catamenia.  [To  face  p.  722_ 


PLATE   LXXXIX. 


Natural  size  of  mounted  seetiou,  4  x  2|  cm. 


Natural  size  of  mounted  section,  o  cm.  7  m.  -X  1  cm.  8  m. 


Photogeaphs  of  Teaxsveese  Sections  of  Scleeosed  and  Cieehotic  Ovaeies, 

IN  WHICH  THEEE  HAS  BEEN  InTEESTITIAL  FiBEOSIS  FOLLOWED  BY  ObLITEKATION 
OF  THE  COEPOEA  LuTEA  AND  FOLLICLES,  WITH  CTSTIC  DEGENERATION  AEISING 
FROM    BOTH    OF    THE    LATTER. 


PLATE   XC. 


Section  of  Sclerosed  axd  Cystic  Ovaet.     (Atthoe.) 
4|  cm.  X  "21 — natural  size  of  the  roonnted  section  (see  Plate  XCII.)- 


Divided  XoDrLAE  Fallopiax  Tube,  removed  with  the  s.aiie  Ovary. 

(Aethor.) 

Tlie  patient,  aged  34,  married  eleven  years ;  five  pregnancies,  no  miscarriages ; 
last  labour  thirteen  months  since.  For  five  years  had  liad  constant  pain 
in  the  left  side  an<l  left  leg.  Of  late  had  been  unable  to  -walk,  and  her 
general  health  had  failed.  The  ovary  which  was  removed  presented 
through  its  entire  extent  sclerotic  degeneration.  Dr.  Cuthbert  Lockyer 
examined  the  specimen. 

The  capsule  was  thickened.  The  stroma  was  studded  all  through  with  cystic 
cavities,  the  remains  of  Graafian  follicles  and  corpora  lutea.  Areas  of 
modified  fibrous  tissue  represented  the  latter ;  there  were  round-celled 
exudation  of  the  stroma  and  thickening  of  the  tunica  albuginea.  The 
walls  of  the  vessels  were  seen  greatly  thickened,  their  appearance  somewhat 
similar  to  the  condition  seen  in  arterio-capillary  fibrosis  of  the  kidney. 
There  were  no  adhesions  of  ovary  or  tube. 

The  tube  was  typically  nodular  in  appearance,  and  measures  4  cms. ;  its  uterine 
cut  end  is  normal  in  size,  its  proximal  end.  1  cm. ;  it  then  enlarges  and 
becomes  very  tortuous,  its  maximum  circumference  measuring  3  cms.  It 
was  split  down  the  middle  along  the  whole  of  its  dilated  part,  and  on 
section  all  the  constituent  parts  of  its  walls  were  thickened,  the  muscular 
layer  swollen  and  the  plicae  oedematous,  while  the  fimbrise  were  fleshy  and 
also  swollen.     There  were  no  areas  of  caseation. 


PLATE   XCir. 


MiCKOScopiCAL  Appeaeances,  fkom  Centee  of  Section,  h — b,  Plate  XC.     x  90. 

(Author.) 

Showing  the  anuular  arrangement  of  the  fibrous  elements  around  the  follicle  which 
is  denuded  of  epithelium,  with  surrounding  librotic  and  hardened  connective 
tissue  elements. 


PLATE   XCIII. 


r.  i.''u-  >f>-. 


.•■--J-.I^JIS!!' 


/^  -    ;: 


'.V 


4 


MiCEOSCOPICAL    ArPEAEAKCES — CORTEX    OF   PlATE    XC.  (a).        X    110. 

Interstitial  fibrosis  and  cystic  degeneration  in  the  sclerosed  area. 


AFFECTIONS  OF   THK    OVARrES— OVARITIS.  728 


tliat  the  corpus  Intonin  takes  an  active  part  in  preserving  the  circulation  of 
the  ovarian  stroma,  and  hence  the  function  of  ovulation ;  while  the  cessation 
of  the  latter  is  induced  by  densiiication  of  the  ovarian  stroma  and  destruction 
of  the  peripheral  circulation,  preventing  the  development  of  the  follicle.* 

Sclerosis.— In  chronic  ovaritis  the  connective  tissue  is  gradually 
ti-ansformed  into  dense  and  undulating  fibrous  tissue,  poor  in  cells 
and  bloodvessels.  The  connective  tissue  is  thickened  around  the 
vessels,  encroaching  on  the  corpora  lutea  and  the  ovarian  follicles. 
Such  a  condition  leads  on  to  sclerosis,  and  in  the  new  formation  are 
variously  shaped  spaces,  remains  of  bloodvessels,  lymphatics,  or 
ovisacs,  thus  leading  up  to  the  serous,  sero-sanguineous,  and  sangui- 
neous cystic  condition.  In  chronic  cortical  ovaritis  the  ovary  is 
surrounded  by  false  membranes,  in  which  may  be  found  sanguineous 
collections.  The  process  of  sclerosis  invades  the  ovary,  with  varying 
degrees  of  thickness ;  the  resulting  obstruction  to  the  circulation 
favours  a  serous  effusion  into  the  follicles,  and  possibly  ha^morrhagic 
infarctions.  This  is  followed  by  general  disorganization  of  the  ovary, 
in  which  a  sclerosed  capsule,  cystic  follicles,  hjemorrhagic  cysts, 
hiemorrhagic  interstitial  effusions,  and  interstitial  sclerosed  changes, 
are  found  on  a  section  of  its  substance. 

Other  Forms  of  Chronic  Ovaritis. 

Cirrhosis. — The  remaining  forms  of  chronic  ovaritis  are  distin- 
guished by  varying  degrees  of  hypertrophy  and  development  of 
fibrous  tissue  in  the  interstitial  stroma  of  the  ovary,  around  the 
vessels,  and  in  the  vicinity  of  the  ovisacs  and  the  follicles.  The 
consequence  is  a  contraction  of  the  ovarian  stroma,  which  presents, 

envelope  derived  from  the  adjacent  part  of  the  stroma,  which  consist  of  fine 
connective-tissue  with  spindle  cells  ;  (2)  a  very  delicate  structureless  membrana 
pellucida ;  (3)  an  irregular  thick  epithelial  layer  of  columnar  ceils,  the  mem- 
brana granulosa,  which  at  one  part  is  thickened,  forming  the  discus  proliferus ; 
(4)  within  this  is  a  drop  of  clear  liquor  folliculi,  in  which  floats  a  nucleated  cell, 
the  ovum.  Kupture  of  a  Graafian  follicle  occurs  at  each  menstrual  period,  and 
the  cavity  of  the  burst  follicle  becomes  filled  with  an  exudation  of  a  peculiar 
reddish-yellow  colour,  becoming  cicatricial  tissue,  with  a  radial  arrangement  of 
its  fibres,  formed  by  the  infiltration  of  the  stroma  cells  and  the  follicle,  and  their 
proliferation  as  a  folded  wall  (corpus  luteum),  which  gradually  diminishes  by 
the  growth  into  it  of  normal  stroma  cells  after  the  tenth  day,  but  does  not 
disappear  for  about  two  months.  If  the  ovum  become  impregnated,  tlie  corpus 
luteum  is  large,  showing  a  trace  of  a  central  cavity  owing  to  the  increased 
vascularity  of  all  the  parts,  and  does  not  disappear  for  about  eight  months.  Some 
new  follicles  collapse  and  shrivel  without  rupture.'  ("Text-Book  of  Human 
Anatomy,'  by  Alexander  Macalister,  F.E.S.) 
*  Brit.  Gijn.  Jour.,  May,  1901. 


724 


DISEASES   OF    WOMEN. 


at  least  in  part,  an  atrophic  or  cirrhosed  condition.  Mingled  in  this 
cirrhotic  tissue  are  small  purulent  deposits,  the  remains  of  separated 
follicles  and  cystic  cavities.  Such  pseudo-hypertrophic  changes  are 
to  be  kept  quite  apart  from  true  hypertrophy  (Lawson  Tait  and 
Slavjansky),  in  which  the  normal  tissues  of  the  ovary  are  greatly 
enlarged. 

Colloid  Degeneration  of  the  Ovary. — Under  this  name  Mary  Dixon  Jones 
has  described  what  she  calls  '  the  fourth  hitherto  undescribed  disease  of  the 

OA'ary.'  It  is  a  form 
of  degeneration 
which  affects  espe- 
cially the  ova  them- 
selves. It  takes  the 
form  of  an  infiltration 
of  the  whole  ovary 
with  colloid  cor- 
puscles. Not  only 
the  ova,  but  also  the 
interstitial  connec- 
tive tissue  and  the 
walls  of  cysts,  become 
affected.  In  ad- 
vanced cases,  not  a 
single  healthy  ovum 
is  found  in  the  whole 
ovary.  When  an  in- 
dividual ovum  so  af- 
fected is  examined 
under  a  very  high 
power,  it  is  seen  that 
the  colloid  change  in- 
volves the  endothelial 
covering  of  the  ovum, 
the  yolk,  the  nucleus, 
and  even  the  nucleo- 
lus. This  form  of 
degeneration  is  re- 
garded as  due  in 
every  case  to  some  form  of  infection,  dating,  in  most  cases,  from  an  attack 
of  gonorrhcBa,  or  from  sepsis  complicating  childbirth.  It  is  frequently  found 
in,  conjunction  with  endothelioma  and  gyroma ;  and  the  former  is  described 
as  being  itself  the  seat,  in  some  cases,  of  colloid  degeneration. 

Fig.  487  gives  a  general  view  of  an  ovary  affected  with  this  form  of  degenera- 
tion.    Figs.  489,  490  show  how  the  disease  attacks  the  ova.     In  sections 


Fig.    487.*  — Ova 
Degeneration. 


IN    A    High    Degree    of    Colloid 
(X  600.)    (Mart  Dixon  Jones.) 

S,  smooth  colloid  corpuscle ;  G,  granular  colloid  masses  ; 
V,  shrivelled,  colloid  vesicula,  in  a  vacuola ;  E,  heap 
of  colloid  corpuscles,  mostly  in  the  epithelia ;  E,  short 
columnar  epithelia  in  an  incipient  colloid  infiltration; 
C,  0,  colloid  corpuscles  in  the  muscle  tissue  of  the 
ovary. 


*  See  also  Figs.  488,  489,  490. 


AFFECTIONS  OF  THE   OVARIES— OVARITIS. 


72.') 


Fig.  488. — Xoemal  Graapiax  Follicle  with  Oyum.    (x  1200.) 
(Mary  Dixox  Joses.) 

MG.  macula  germinativa ;  VG,  vesicula  germinativa ;  C,  cuticula ;  Y,  yolk ; 
E,  flat  epithelium ;  S,  structureless  or  basement  membrane ;  CO,  connective 
tissue  capsule ;  ML,  smooth  muscle  fibres  in  longitudinal  section  ;  MT, 
smooth  muscle  fibres  in  transverse  section. 


Fig.  -iSli. — Combined  Fatty  axd  Colloid  Dkgexeratiox  of  Ovum,     (x  COO.) 

(Mauy  Dixon  Jones.) 

E,  short  columnar  epithelium,  in  colloid  infiltration;  F,  fat  globules;  G,  coarsely 

granular  colloid  masses ;  C,  colloid  corpuscles  in  muscle  layer  of  ovary. 


726 


DISEASES   OF   WOMEX. 


showing  colloid   degeneration,  the  tissues  other  than  the   ova  themselves 
generally  appear  in  a  condition  of  acute  inflammation. 

c 

9(^ 


Fig.  -±90. — Colloid  Degeneration  of  the  Ovary,     (x  500.) 
(Maky  Dixon  Jones.) 

G,  G,  colloid  corpuscle^  ;  0,  ovum  ;  A,  artery  ;   V,  vein. 


Cystic  Ovaritis, 
Hydro-cystic. 

In  the  hydro-cystic  degeneration  of  the  ovarian  stroma  there  is  an  attendant 
sclerosis.  The  follicular  cysts  are  unilocular  and  spherical,  varying  from  the 
size  of  a  small  cherry  to  a  walnut,  and  occasionally  larger.  Such  cystic 
degeneration,  with  the  associated  hypertrophic  changes,  may  increase  the 
size  of  the  ovary  to  that  of  the  closed  jBst.  On  section  the  cyst  presents  a 
wall  with  a  double '  contour  and  a  smooth  surface,  and  it  is  filled  with  a 
colourless  and  limpid  fluid.  Ovules  are  not  found  in  those  of  a  smaller  size. 
They  disappear  in  the  cell-proliferation  which  accompanies  the  cystic  forma- 
tion, when  the  normal  epithelium  passes  into  a  granular  or  colloidal  degenera- 
tion. These  dropsical  follicles  are  situate  in  a  suiTOunding  bed  of  sclerosed 
ovarian  tissue.     With  this  the  wall  of  the  follicle  is  finally  blended,  so  as  to 


PLATE   XCIV. 


\^^ 


Ovarian  Blood  Sac.     (See  also  Plate  XCVIII.) 

Natural siz9.     Drawn  after  removal' of  the  tumour  and  before  the  blood  was 

evacuated. 

[To  face  p.  726. 


PLATE    XCV. 


ISTEEIOR    OF    SA3IE    SaC    (PlATE    XCIV.)- 

Drawu  after  removal  of  the  blood  and  preparation  of  tlie  specimen.  The 
bilocular  nature  of  the  cyst  is  shown,  -with  the  Fallopian  tube  attached 
to  the  summit  of  the  sac,  not  opening  into  it. 

[To /ace  jj.  727, 


AFFECTIONS   OF  THE   OVARIES— OVARITIS.  T21 

destroy  all  trace  of  tlie  ilistinctive  follicular  wall.  This  hydro-cystic  change 
in  the  follicles  of  the  ovary  may  be  attended  by  a  corresponding  drop.sical 
degeneration  (serous  pseudo-cysts)  in  the  stroma,  the  result  of  oedema. 

Haemato-cystic. 

The  sanguineous  or  haemorrhagic  cysts  vary  greatly  in  size.  (T  have 
removed  several  such.  In  one  case  there  was  an  ovarian  blood-cyst  at  either 
side — each  cyst  the  size  of  an  orange.  These  were  taken  entire,  and  without 
rupture.  The  patient  made  an  admirable  recovery.  She  had  been  for  years 
sulfering.)  The  smaller  or  multiple  (hajmato-follicular)  are  disseminated 
throughout  the  entire  ovarian  stroma ;  this,  according  to  Petit,  represents  the 
mode  in  which  septicemic  ovaritis  affects  the  organ.  The  larger  ones  are 
more  probably  due  to  a  hsemoiThage  into  the  interior  of  a  hydro-cyst.  This 
variety  is  associated  with  a  cortical  sclerosis.  The  cyst  has  a  fibrous  wall  of 
varying  consistence.  The  parietal  epithelium  is  altered  or,  more  generally, 
destroyed.  Other  blood-cysts  are  associated  with  the  physiological  rupture 
of  the  Graiifian  follicles.  The  microscopical  features  of  such  cysts  serve  to 
distinguish  them. 

Differentiation  of  Blood-Cysts  of  tlie  Ovary. — Bender,  having  investigated 
the  character  of  the  blood  in  twenty-three  cases  of  ovarian  blood-cysts, 
arrives  at  the  conclusion  that  when  there  is  a  number  of  leucocj^tes  present 
(varj'ing  fi'om  six  to  eight  thousand)  with  the  normal  number  of  red  blood 
cells,  the  cyst  is  benign;  when  the  red  cells  diminish  in  number  in  the 
presence  of  leucocytes,  malignancy  may  be  suspected.* 

In  the  interstitial  haemorrhagic  cyst  the  flow  of  blood  has  been  more 
diffused.  The  extravasated  blood  becomes  encysted,  and  the  entire  substance 
of  the  ovary  may  thus  be  of  the  consistence  of  the  splenic  pulp.  This  class 
of  hasmorrhage  more  frequently  follows  acute  ovaritis. 

Double  Paroophoritic  Blood-cysts. — The  ovaries  and  Fallopian  tubes  of 
a  married  woman  (one  previous  pregnancy),  aged  39,  were  removed  by 
the  author.  She  had  suffered  from  retroversion  of  the  uterus.  Notwith- 
standing palliative  treatment,  she  continued  to  suffer  great  pain,  and  life  became 
intolerable.  On  operating,  a  large  paroophoritic  cyst,  with  the  Fallopian  tube 
lying  over  it,  was  found  at  either  side.     The  cysts  were  filled  with  blood. f 

Fig.  491  represents  '  apojdexy  of  the  ovary ' — the  clironic  hsemato-cystic 
hsemorrhage  of  Petit.    It  shows  a  tumour  removed  by  Alban  Doran.;}: 
In  referring  to  this  case  Doran  says — 

'  The  general  appearance  of  the  diseased  ovary,  and  the  relations  of  the 
corpus  luteum  to  the  cavity,  indicated  a  pathological  condition  which  bore  no 
relation  to  incipient  cystoma  of  the  organ. 

'  No  rent  nor  cicatrix:  of  a  rent,  nor  any  aperture  nor  fistulous  track,  could 
be  detected  on  the  surface  of  the  ovary.  The  two  dilated  follicles  bore  no 
cicatrices. 

*  Bev.  de  Gyn.  et  de  Gliir.  Ahd.,  July-Aug.,  1903.         t  Brit.  Gyn.  Jour.,  1893. 
X  Obstetrical  Society's  Transaction'^,  1890. 


728 


DISEASES   OF   WOMEX. 


'  The  tviraour  consisted  of  the  right  ovary.     It  weighed  two  ounces,  and 
measured  two  inches  and  a  half  in  vertical  diameter,  and  one  inch  and  five- 
eighths    horizon- 


OVARY 


Fig.  491. — Apoplexy  of  the  Ovaey. 


tally.  The  surface 
was  of  a  dull  drab 
colour,  and  puck- 
ered. A  large, 
single  -  chambered 
cavity  occupied  the 
interior  of  the 
ovary.  It  was  filled 
with  a  tough  yellow 
substance.  The 
membrane  in  zig- 
zag folds  was  de- 
ficient towards  the 
yellow  substance, 
so  that  it  partially 
enclosed  a  space 
(resembling  in  all 
respects  the  cavity 
of  a  well  -  formed 
corpus  luteum) 
which,  where  not 
bounded  by  the 
membrane,  opened 
out  against  the  yel- 
low substance.  On 
removing  the  sub- 
stance from  the 
cavity  in  which  it 
was  embedded  in 
one    of    the    half- 


(DOEAX.) 

sections,  the  space  partially  enclosed  by  the  zig-zag  membrane  was  found  to 
open  out  into  that  cavity.  The  above  appearances  indicated  the  rupture  of 
a  mature  follicle  into  the  stroma,  with  subsequent  hfemoiThage.' 

Olshausen  divides,  ovarian  ajioplexj^  into  two  varieties :  haemorrhage  into 
the  follicles  and  haemorrhage  into  the  stroma.  In  pure  examples  of  the  second 
variety,  which  follow  local  congestion  and  are  seen  as  complications  of  scurvy, 
typhoid  and  other  fevers,  the  stroma  becomes  converted  into  a  spongy  sub- 
stance full  of  fluid  blood,  resembling  the  spleen. 

The  present  specimen,  as  proved  by  the  appearances  described,  is  an 
example  of  ovarian  apoplexy  originating  in  a  follicle,  but  involving  the  stroma 
through  rupture  of  the  folHcle.  Olshausen,  who  recognizes  this  secondary 
form  of  haemorrhage  into  the  stroma,  describes  an  apparently  similar  case. 
Whilst  small  apoplexies  disappear,  as  a  rule,  through  reabsorption,  and  leave 
no  trace  behind,  large  effusions  may  lead  to  the  partial  or  complete  destruction 
of  the  parenchyma,  involving  in  the  latter  case  the  conversion  of  the  ovary 
into  a  single  cyst,  filled  with  a  thick,  greas}'  mass.' 


PLATI^:    XCVI, 


Lakge  Eight  Ovakiax  Pus  Sac  with  the  Portion  of  the  Tube 
OPEXIXG  into  the  Sac.     (Authok.) 

Both  ovary  and  tube  were  embedded  in  adhesions,  the  sac  wall  being  lined  with' 
swollen  papillary  granulations. 

PLATE    XCVII. 


Smaller  Left  Cystic  and  Gyromatous  Ovary  with  Sclerosed  Capsule  with 
THE  Cystic  Tube  removed  from  the  same  Patient.     (Author.) 

See  other  side  for  abstract  of  the  Histological  Report  of  these  adnexa. 

[To /ace  f..  728. 


Eiglit  and  Left  Salpingo-Oophoritis,  with  Pas  Cysts  of  Ovaries. 

The  patient  from  whom  the  adnexa  (Plates  XCYI.,  XCMI.)  were  removed 
had  been  married  for  twelve  years.  She  had  had  two  children  at  full  term,  and 
two  miscarriages.  Her  last  pregnancy  was  nine  years  since.  Uterine  hfemor- 
rage  commenced  about  two  years  ago,  and  occasionally  was  very  excessive.  It 
was  associated  with  great  pain  in  the  left  side  and  over  the  sacrum.  Offensive 
clots  were  passed  occasionally,  and,  after  these,  watery  discharges.  Seven  years 
previously  the  uterus  had  been  curetted.  At  the  time  of  operation  she  was 
very  weak,  and  walked  with  difficultly.  At  operation,  a  cyst  about  the  size  of  an 
orange  was  found  in  Douglas'  space  at  the  right  side,  with  a  very  enlarged  and 
dilated  oviduct,  and  at  the  left  side  an  enlarged  and  diseased  ovary  with  a 
correspondingly  thickened  tube.  At  both  sides  the  adnexa  were  buried  in 
plastic  lymph.  The  pus  sac  ruptured  on  the  point  of  delivery,  but  very  little 
pus  escaped  into  the  abdominal  cavity.  After  removal  of  the  adnexa  the  pelvis 
was  freely  mopped  out  with  swabs  wet  with  formalin  solution.  The  tubes  had 
the  appearance  of  tuberculous  salpingitis,  and  the  associated  pus  cyst  made  me 
suspicious  that  the  trouble  might  be  of  tuberculous  nature. 


Abstract  of  Histological  Report  on  the  Adnexa  (Plates  XCVI.,  XCVII.). 

'  The  Tubes.* — In  the  large  tube  (the  one  attached  to  the  ovarian  cyst),  the 
mucosa  is  nearly  entirely  replaced  by  granulations,  only  a  few  columnar  tubes 
being  left  to  represent  plicje.  Under  the  peritoneum  are  seen  granulomatous- 
looking  areas,  circular  and  oval,  consisting  of  round-celled  infiltration  surrounded 
by  a  fibrous  capsule.  The  entire  musculo-iibrous  wall  is  infiltrated,  and  the 
vessels  contained  in  it  have  thickened  walls.     Xo  giant-cells  are  seen. 

'  The  smaller  tube  shows  plicse,  which  are  swollen  by  leucocytic  infiltration  ; 
the  mucosa  between  the  plicse  is  also  infiltrated  in  like  manner.  There  are  no 
subperitoueal  deposits,  but  no  doubt  this  tube  shows  the  same  process  as  that 
seen  in  the  larger  one,  only  in  a  much  earlier  stage.  Xo  giant- cells  are  seen. 
It  has  a  pervious  abdominal  ostium,  near  to  which  is  a  cyst  the  size  of  a  filbert- 
nut  ;  this  proceeds  from  the  lower  attached  margin  of  the  tube.  The  latter  is 
thickened,  but  to  a  far  less  degree  than  its  fellow.' 

'  The  Ovaries. — The  cyst  measures  7  cm.  in  long  diameter,  and  5  cm.  in  the 
vertical.  Opening  into  its  upper  and  inner  aspect  is  the  tube :  the  point  of 
entrance  is  indicated  by  a  bristle.  The  tube  is  much  thickened,  measuring 
2  cm.  in  thickness  at  its  cut  extremity.  The  cyst-wall  is  studded  by  what,  to 
the  naked  eye,  look  like  small  yellow  papillomata,  about  the  size  of  a  pin's 
head.  The  cyst-wall  contains  loculi,  probably  the  remains  of  Graafian  follicles, 
and  it  varies  considerably  in  thickness,  from  1  cm.  to  3  cm.  Externally  are 
seen  ragged  adhesions  of  organized  lymph. 

'  The  smaller  ovary  measures  3'5  cm.  in  the  vertical,  and  3  cm.  in  the  trans- 
verse diameter.  Its  surface  is  puckered,  and  covered  by  organized  lymph. 
There  was  cystic  degeneration,  and  gyromatous  clianges  were  present  through- 
out the  ovary.' 

*  See  Plates  LIL,  LIU. 


PLATE    XCVUr. 


Pyo-ctstic  Ovaey  bisected;   eemoted  by  Abdomixal  Cceliotomy. 

(Author.) 

The  adiiexa  were  embedded  in  adhesions.     The  tube  was  incorporated  with 

the  wall  of  the  sac;  not  opening  into  it. 


E.\.TERN'.\L    SUKFACE    OF    SA3IE    AbNEXA,    SIKiWIXG    THE    AUHESIONS    AND 
I^"C'0EP0KATED    TlBE. 


PLATE    C. 


TCBO-OVARIAN   PyO-CYST — SaC   OPEXED    TO    SHOW   INTERIOR — TuBE   OPEXINS 

INTO  THE  Sac — Abdominal  Cceliotoihy.    (Author.) 


PLATE    CI. 


External  Surface  of  the  Ovary— the  Adherent  Tube  has  been 
dissected  out  from  the  Bed  of  Adhesions. 

[To  face  p.  729. 


AFFECTIONS  OF  THE   OVARIES— OVARITIS.  729 

Pyocystic  Ovaritis 

This  begins  generally  in  the  ovisacs,  or  in  the  lymphatic  spaces, 
in  the  form  of  small  multiple  abscesses,  which  are  gradually  Ijleuded 
by  fusion  of  their  walls  through  necrosis  of  the  interposed  embryonic 
tissue.  The  size  varies.  They  frequently  are  imbedded  from 
within  outward  in  embryonic,  fibrous,  and  cellulo-vascular  tissue. 

Bonnet  and  Petit  record  a  case  in  which  a  follicular  cyst  contained  an 
abscess  the  size  of  a  pigeon's  egg.  This  cyst  was  situated  near  a  larger  one 
of  the  same  nature,  tlie  contents  of  which  were  serous,  ond  the  surrounding 
stroma  was  normal.  The  pyogenic  germs  they  consider  were  carried  by  tlie 
vessels  of  the  liilura.  They  point  out  that  an  ovarian  abscess  in  developing 
itself  has  a  tendency  to  double  over  the  broad  ligament,  so  as  to  assume  the 
appearance  of  a  phlegmon  of  the  latter.  Such  a  doubling  over  is  very  decep- 
tive, and  in  operation  is  apt  to  be  mistaken  for  a  broad  ligament  cyst. 

Briefly,  I  may  summarize  the  progressive  changes  that  occur 
thus — 

1.  FolUcnlar  degeneration  of  Graafian  follicles. 

2.  Interstitial  changes  in  the  stroma — neoplasms,  sclerosis,  cirrhosis, 
encysted  abscesses. 

3.  Suh peritoneal  thickening  of  the  albuginea  due  to  peritoneal 
inflammation. 

4.  Various  adhesions  of  the  ovaries  to  the  surrounding  pelvic 
structures. 

5.  Liquefaction  of  interfitifial  effusions  of  h/mph  and  hlood,  furnish- 
ing secondary  serous,  caseous,  and  sanguineous  contents  of  cysts. 

We  are  especially  indebted  to  Nagel,  Gussei'ow,  and  Petit  for 
more  accurate  knowledge  of  these  pathological  changes. 

Causation. — A  case  of  uncomplicated  ovaritis  is  rare.  Still,  we 
occasionally  meet  with  it,  both  as  a  result  of  chill  taken  at  the 
menstrual  period,  and  in  the  early  stages  of  gonorrhea. 

Zymotic  Causes. — During  my  eleven  years'  connection  with  the  Cork  Fever 
Hospital,  I  saw  marked  cases  of  ovaritis  in  patients  suffering  from  typhoid 
fever.  It  is  of  course  impossible  in  such  cases,  or  in  the  exanthemata,  to 
say  how  far  the  ovaries  may  have  been  involved  by  previous  inflammatory 
or  degenerative  changes.  Again,  in  tyj^hoid  fever  we  can  readily  under- 
stand how  the  ovaries  may  become  involved  in  the  adjacent  peritoneal  and 
glandular  mischief. 

Alcoholic  Abuse. — Matthews  Duncan  attributed  the  occun^ence  of  ovaritis 
frequently  to  the  abuse  of  alcohol.  Eeflex  excitement  of  the  ovarian  nerves 
may  originate  it,  much  in  the  same  manner  as  orchitis  occurs  in  the  male. 
Hence  we  have  it  following  excessive  sexual  intercourse,  masturbation,  and 
the  passage  of  the  uterine  sound.    I  have  no  doubt  that  such  reflex  nerve 


730  DISEASES   OF    WOMEX. 

disturbance  frequently  leads  to  more  grave  results  than  we  could  possibly 
anticipate  from  so  slight  an  exciting  cause  as  the  use  of  the  sound.  I  believe 
analogous  febrile  conditions  in  the  female,  as  that  which  Sir  Andrew  Clark 
drew  attention  to  in  the  male  as  arising  from  the  passage  of  the  catheter, 
vaaj  be  accounted  for  in  precisely  the  same  manner. 

Diagnosis. — The  enlarged  and  painful  ovary  may  be  felt  (a)  by 
palpation,  through  the  abdominal  wall ;  (&)  by  the  vagina,  by  a 
careful  digital  and  bimanual  examination  ;  (c)  by  rectal  exploration, 
and  especially  by  the  conjoined  recto- vaginal  examination.  It  may 
vary  in  size,  feeling  about  the  size  of  a  large  almond,  or  even  of  a 
pigeon's  egg.  Pressure  on  the  ovary  excites  pain.  Unfortunately, 
however,  pain  in  a  neurasthenic  woman  can  be  greatly  exaggerated. 
We  must  largely  discount  this  hyper-sensitiveness  complained 
of  when  making  our  diagnosis,  and  not  attach  too  great  an  im- 
portance to  it. 

'  Who,'  asks  Emmet,  '  are  the  sufferers  from  a  condition  which  has  been 
termed  an  irritable  ovary  f  The  young  girl  who  has  had  her  bi'ain  developed 
out  of  season ;  the  woman  who  has  been  disappointed  or  crossed  in  love  by 
some  man  not  worthy  of  her '  (and,  he  might  have  added,  the  girl  who  is  made 
the  subject  of  unsatisfying  and  exciting  embraces,  indulged  in  during  long 
engagements) ;  '  those  who  have  been  Hi-mated  and  often  unmated ;  she  who 
has  sold  her  person,  under  the  guise  of  marriage,  for  money  or  position;  the 
prostitute ;  and  she  who  degrades  herself  and  sacrifices  her  womanhood  by 
resorting  to  means  to  prevent  conception.  In  all  of  these  the  nervous  system 
has  been  first  abused,  and  then  nutrition  has  suffered,  some  accident  only 
locating  the  effects  in  the  ovary.' 

Symptoms  and  Physical  Signs. — These  wUl  depend  on  the  severity 
of  the  attack,  the  presence  of  any  collateral  disease,  or  the  acute 
or  chronic  nature  of  the  afiection.  Ovarian  congestion  may  be 
accompanied  by  any  form  of  pelvic  or  uterine  inflammation.  Hence 
the  gravity  of  the  symptoms  will  depend  on  the  nature  and  course 
of  the  attack.  This,  as  we  have  seen,  may  cease  at  active  hypersemia, 
or  may  run  on  to  pelvic  abscess  and  pyo-salpinx  or  ovarian  abscess 
and  pyo-cyst.  Ovaritis,  acute  and  chronic,  may  be  attended  by 
any  or  all  of  the  following  symptoms  :  oophoria ;  dysootocia ;  dys- 
menorrhcea ;  dyspareunia ;  hysteria  and  hystero-epilepsy  ;  various 
reniote  (reflex)  pains ;  neuralgia ;  inability  to  walk ;  pain  in 
defsecation ;  sterility.''* 

Treatment. — Complete  rest  when  there  is  any  acute  inflamma- 
tion ;  the  knee-elbow  position  assumed  for  some  time   daily ;   the 

*  See  chapter  on  Uterine  Eeflexes,  p.  321. 


PLATE    CIT. 


Sections  of  Eesected  Portioxs  of  Ovaries  (x  2)  removed  from  Patients 

AT  THE  Same  Time  that  the  Uteeus  was  Ventro-suspexded. 
The  albuginea  was  thickened ;  there  was  sclerosis  of  the  cortex  with  cystic 
degeneration.  The  deeper  stroma  was  found  cellular,  the  follicles  atresis 
and  degenerate,  and  reduced  in  numbers.  There  were  corpora  lutea  in  all 
stages  of  evolution,  some  cystic  with  an  excess  of  lutein  colls  in  their 
walls.  Severe  adnexal  pain  and  dysmenorrhoea  were  added  to  the  symptoms 
due  to  the  retro-displacement  (Cuthbert  Lockyer's  Keport). 

[To  face  p.  730, 


PLATE    CUT. 


Macroscopical  Appear axces  of  a  Cystic  and  Sclerosed  Ovary  with 
Portion  of  Tube. 

This  ovary  was  removed  from  a  patient  (unmarried)  wlio  suffered  for  years  from 
adnexal  i^ain  and  severe  dysmenorrlicea.  The.other  ovary  had  been  removed 
two  years  previously.  It  was  a  large  cystic  ovary.  The  uterus,  which  was 
retroflexed,  was  at  the  same  time  ventro-,suspended. 

\_To  face  p.  731. 


AFFECTIONS   OF   THE    OVARIES— OVARITIS. 


731 


raising  of  the  foot  of  the  bed  or 
four  inches  by  blocks  of  wood 
avoidance  of  sexual  intercourse 
the  .anus;  vesication  over  the 
applied  over  the  same  part,  or 
liniment  of  belladonna  (^ss.), 
rectified  spirit  (^i.),  laid   on  w 


couch  on  which  the  patient  lies  about 
or  long  castors  (Heywood  Smith) ; 

;  leeches  to  the  inguinal  region  or 
inguinal  region  ;  iodine  '  pigment ' 
a  combination  of  chloroform  {"^i.), 

mastich   (^ii.),  camphor   (5ii.),  and 

ith  a   thick  brush.      This  is  an  ad- 


FiG.  402. — Leiter's  Irrigator.        Fig.  -iD^. — Leitek's  Ikiugatok  applied. 

mirable  application  to  relieve  pain.  It  forms  a  pigment,  and  can 
be  reapplied  daily.  Leiter's  irrigator  can  be  applied  during  in- 
flammatory states.  The  bromides  can  be  given  internally,  and,  in 
the  chronic  stage,  iodide  of  potassium.  If  dysmenorrhoea,  hysteria, 
hystero-epilepsy,  or  neuralgia,  persist,  rendering  the  woman's  life 
miserable,  the  operation  of  salpingo-oophorectomy  has  to  be  con- 
sidered. 


DISEASES  OF  THE  OVARIES  AND  FALLOPIAN  TUBES 
IN  CHILDREN.* 

Diagnosis  of  Ovarian  Disease  in  Children. 

As  illustration  of  the  value  of  bimanual  and  rectal  examination  in  the 
young  child,  George  Carpenter  mentions  the  case  of  the  diagnosis  of  an 
ovarian  cyst  in  a  child,  22  months  old,  where  the  tube  was  also  involved,  and 
in  which  the  diagnosis  was  veri6ed  b}'  operation.f 

We  may  classify  the  aifections  of  the  ovaries  in  childhood  under 
the  head  of  malformation,  hernia,  cystoma,  sarcoma,  carcinoma, 
and  tuberculosis.     Bland-Sutton  has  described  the  tumours  of  the 

*  I  have  already  referred  to  the  importance  of  rectal  examination  in  tlie 
diagnosis  of  diseases  of  the  genital  organs  in  children. 

t  See  also  chapter  on  First  Steps  of  Examination  of  a  Case,  rectal  examination 
and  bimanual  in  cliildren  (G.  Carpenter),  p.  92. 


732 


DISEASES  OF   WOMEN. 


oophoron,  under  the  head  of  the  oophoromata,  and  a  hundred  cases 
of  ovariotomy  in  children  under  sixteen,  as  performed  by  various 
surgeons.     Such  tumours  may  arise  in  the  connective  tissue  of  the 


cotiVoJureJ  IZche.  Q-tf-UchcJ. 


Fig.  494.  —  Condition  op  the  Internal  Female  Genitalia  in  a  Child 
Twenty-two  Months  old,  determined  bt  Eectal  and  Bimanual 
Examination.     (G.  Carpenter.) 

oophoron  or,  as  Doran  has  shown,  in  its  embryonic  tissue.  Most 
cystomata  in  children  are  found  when  the  girl  approaches  puberty, 
as  large  a  proportion  as  one-half  being  discovered  about  this  time. 


Fig.  495.— Drawing  of  the  Ovarian  Tl-mour  and  Fallopian  Tube  as  it 

APPEARED    on   KeMOVAL.       (G.    CARPENTER.) 

Diagnosis. — The  danger  of  overlooking  a  tumour  of  the  genital 
organs  in  children,  or  of  mistaking  it  for  an  enlargement  or  growth 
from  some  other  organ,  is  greater  than  the  liability  to  error  once 
such  a  condition  is  suspected.     Under  chloroform,  the  bowel  and 


PLATE   CIIlA. 


Sections  of  Ovaries  of  a  Still-born  Child,  showing  Cystic  Degeneration. 

These  sections  were  made  by  Professor  Shroeder  at  Professor  Fritsch's  Klinik 
at  Bonn,  and  given  there  to  the  author  (190i). 

[To  face  p.  732. 


AFFECTIONS    OF   THE   OVARIES— OVARITIS.  733 


bladder  being  empty,  there  can  be  little  difficulty,  by  a  gentle  yet 
thorough  rectal  and  vaginal  examination  bi-manually,  in  detecting 
tumours  of  the  adnexa. 

Cystomata. — Kelly  classifies  cystomata  as  adeuo-cystomata,  unilocular  cysts, 
aud  dennoiil  cysts.  At  the  Johns  Hopkins  Hospital,  one-third  of  the  ovarian 
tumours  found  in  children  were  dermoids ;  and,  from  a  case  reported  by 
Emanuel,  it  woidd  appear  that  a  tumour  of  this  nature  may  become  malignant, 
in  his  case  recurrence  taking  place  after  complete  removal  of  the  cyst,  sarco- 
matous elements  having  been  found  in  its  stroma,  the  secondary  sarcoma 
occurring  in  the  omentum  and  abdominal  wall.  Several  cases  have  been 
recorded  of  carcinoma  of  the  ovary  in  children.  Kelly  gives  an  analysis  of 
126  cases  of  tumours  of  the  ovary  occurring  in  children,  in  which  ovariotomy 
was  performed,  50  per  cent,  of  the  children  operated  on  under  four  dying 
after  operation,  whereas  in  those  of  more  advanced  age  the  mortality  was 
much  lower.     In  the  126  cases  there  were  22  deaths. 

Analyzing  these  12G  cases,  we  iind  that  there  were  30  simple  cystic  or 
monocystic  tumours,  24  multilocular  cystoma,  1  adeno-cystoma,  43  dermoids, 
3  teratomata,  16  sarcomata,  1  myxo-sarcoma,  1  semi-solid  tumour,  1  papillary 
cystoma,  6  carcinomata. 

The  proneness  of  children  to  omental,  renal,  and  mesenteric  tumours, 
tubercular  and  other,  has  to  be  remembered,  though  this  does  not  exclude  the 
possibility  of  a  hepatic,  splenic,  or  pancreatic  growth.  As  regards  the  treat- 
ment of  ovarian  growths,  operation  is,  whenever  possible,  the  one  plan  of 
treatment. 

Turning  to  inflammatory  conditions  of  the  adnexa,  the  relation- 
ship of  vulvo-vaginitis  to  ovaritis  and  salpingitis  should  be  noticed,, 
Mark's  post-mortem  examinations  showing  10  per  cent,  of  pus 
tubes  ;  and  the  important  observation  has  to  be  made  that  pyrexia, 
abdominal  pain,  with  general  constitutional  disturbance  and  painful 
micturition,  may  be  due  to  adnexal  inflammation,  to  be  detected  by 
rectal  examination.  Appendicitis  also  may  accompany  the  ovaritis. 
The  exanthemata,  esi^ecially  where  the  exanthem  occurs  in  a  child 
of  strumous  constitution,  may  be  attended  by  an  attack  of  salpingo- 
ovaritis.  Gonorrhoea,  also,  is  to  be  remembered  as  another  source 
of  infection.  In  a  table  published  by  Kelly,  of  115  cases,  97  had 
a  gonorrheal  origin.  The  importance  of  this  relationship  between 
vulvo-vaginitis,  the  presence  of  the  gonococcus,  and  suppurative 
disease  of  the  aclnexa  in  children,  cannot  be  overestimated.  Kelly  * 
records  22  cases  of  tuberculosis  of  the  adnexa  in  children,  of  ages 
vai'ying  from  If  years  to  15  years.  In  half  the  number  the  disease 
occurred  before  the  age  of  six.f 

*  HoMard  Kelly,  ' Cycloptedia  of  Diseases  of  Children.'  vol.  v..  supplement. 
t  For  a   description   of    genital   tuberculosis   in    children,    see   chajjter   on 
Tuberculosis. 


731 


DISEASES   OF   WOMEN. 


Gronorrhoeal  Inflammation  of  the  Uterine  Appendages  in  a  Girl  of 
3|  years,  detected  by  Bimanual  Examinations — Spontaneous 
Recovery.* 

George  Carpenter  reports  the  following  case  :  f — 

'  A  child,  aged  SJ  years,  had  a  vaginal  discharge  of  six  weeks'  duration, 
pains  in  the  lower  part  of  her  abdomen,  and  frequency  of  micturition. 

'  The  pus  from  the  vulva  contained  numerous  gonococci. 

'  On  a  bimanual  examination  of  her  pelvic  viscera  being  made  by  way  of 
the  rectum,  the  uterine  appendages  were  found  to  be  involved. 

'  On  the  right  side  there  was  felt  an  irregularly  shaped  elastic  tumour 
attached  to  the  uterus  at  the  upper  part,  and  from  which  it  could  not  be 
differentiated  (G).  Its  free  extremity  was  movable.  It  presented  a  central 
depression,  and  measured,  at  a  guess,  1\  inches  or  more  lengthwise  and  f  of 


Fig.  496. — Condition  of  Adnexa  deteeminbd  by  Vaginal  and  Rectal 
Examination. 

an  inch  across,  Kolled  between  the  fingers  of  the  two  hands,  there  seemed 
to  be  an  ill-defined  cord  upon  it  at  one  part,  On  the  left  side  the  Fallopian 
tube  apparently  ended  in  a  fusiform  swelling  about  an  inch  long  and  a  quarter 
of  an  inch  broad,  which  was  attached  to  the  side  of  the  pelvis  A.  This  was 
probably  the  enlarged  fimbriated  extremity  of  the  Fallopian  tube.  If  it  were 
the  ovary,  then  that  organ  was  decidedly  enlarged  for  her  age.  Lying  below 
this  body  were  two  rounded  bodies,  somewhat  movable,  one  of  them  being 
about  the  size  of  a  small  pea,  the  other  half  that  in  diameter  (C  and  D).  The 
uterus  felt  natural  except  just  where  it  was  attached  to  the  tumour  on  the 
right  side.  All  the  parts  had  rather  a  woolly  and  indistinct  feel,  which  was 
thought  to  be  possibly  owing  to  associated  pelvic  peritonitis. 

*  See  also  pp.  92  and  93,  the  Pelvic  Organs  in  Children. 

t  Read  at  the  Society  for  the  Study  of  Disease  in  Children,  April  15,  1904. 


AFFECT/ONS   OF    TIIJ-:   uVAllI FS—OVAL'JTJS. 


735 


'Twenty-seven  days  subsequently,  the  pelvic  condition  liad  coiiHidenibly 
changed.  The  left  ovary  and  Fallopian  tube  were  found  to  be  of  natural 
size.  Tiie  right  Fallopian  tube  was  decidedly  enlarged,  and  associated  with 
it  was  a  very  elastic  tumour  half  an  inch  or  more  in  diameter.  The  uterus 
was  then  normal  to  the  feel.  All  parts  were  freely  movable.  There  was 
still  a  purulent  discliarge  from  the  vagina.' 

The  case  remained  under  observation  for  iivc  months ;  by  the  end  of  tliat 
lime,  though  the  vaginal  discharge  still  continued,  while  the  vaginal  mucous 
membrane  and  the  portio  were  reddened  in  patches,  the  adnexa  were  almost 
normal  in  size.  Carpenter  considers  that  in  this  case  there  was  salpingitis 
probably  of  both  sides,  though  whether  the  right  tumour  was  an  enlarged 
tube  or  the  ovary  he  could  not  feel  certain.  The  uterine  appendages  were 
attacked  by  gonorrhocal  inflammation,  and  they  apparently  spontaneously 
recovered  from  it. 

'  There  are  now  a  number  of  cases  of  localized  gonorrhoeal  peritonitis  in  little 
girls  on  record,  but  none  that  I  am  aware  of  where  bimanual  examinations  of 


Fig.  41)7. — Same  Adnexa  examined  Twenty-seven  Days  afterwards. 

the  internal  genitalia  have  been  made  during' the  course  of  these  complications. 
I  therefore  record  the  case  as  an  illustration  of  pelvic  disease  secondary  to 
gonorrhosa,  and  also  as  an  example  of  the  value  of  bimanual  examination  of 
the  internal  genitalia  in  young  children — a  method  which  I  have  long 
advocated,  and  the  technique  of  which  I  have  descilbed.*  There  is  a  further 
value  attached  to  this  case  in  that  it  shows  that  these  conditions,  at  least  in 
sume  instances,  tend  to  spontaneous  recovery,  and  that  without  such  examina- 
tions cases  are  likely  to  be  passed  by.  It  is  interesting  to  speculate  on  the 
effect  such  complications  are  likely  to  produce  as  regards  future  child-bearing. 
Sterility  may  possibly  result  in  some  instances.  Marx  f  is  of  opinion  that 
these  infantile  inflammations  are  apt  to  commence  afresh  at  puberty,  and 
often  are  the  real  cause  of  pelvic  inflammations  of  newly  married  women 
hitherto  frequently  credited  to  the  husband.' 

*  Pediatric',  vol.  i.   pp.  491-500,  'On  the  Value  of  Eectal   Exploration  ae 
an  Aid  to  Diagnosis  in  Diseases  of  Children.' 
I  Gazelle  de  Gynecologie,  Nov.  l."),  18'.)5. 


CHAPTER   XXXVIII. 
OVARIAN    CYSTOMA 

Jltiolog-y  and  Pathology. 


Cysts  :— 

1.  Oophoronic  cysts. 
a.  Simple  cysts, 
h.  Adenomata. 
G.  Dermoids. 


2.  Simple  Paroophoronic  cysts. 

3.  Parovarian  cysts. 

4.  Gartnerian  cysts. 

5.  Tubo-ovarian  cysts. 


Development  of  Ovarian  Cysts. — There  can  be  no  doubt  that 
inflammatory  processes  in  the  ovarian  stroma  give  rise  to  the 
formation  of  cysts  in  the  connective  tissue.  But  such  cystic  de- 
generation may  arise  from  epithelial  degeneration,  from  changes  in 
the  bloodvessels,  or  from  degenerative  changes  in  the  follicles  or 
corpora  lutea.  Hence,  with  ovarian  cysts  we  find  associated  endo- 
theliomatous  and  gyromatous  conditions,  blood  cysts,  and  pus  cysts. 
Mary  Dixon  Jones  made  a  careful  study  of  the  entire  subject,  and 
has  published  her  conclusions  in  1900,  supported  by  microscopical 
evidence.""'  The  general  result  may  be  thus  summed  up  :  Ovarian 
cysts,  whether  commencing  in  the  stroma  and  interstitial  structure 
of  the  ovary  or  in  the  Graafian  follicles,  are  secondary  consequences 
of  inflammatory  processes  which  tend  to  produce  an  embryonal  con- 
dition ending  in  granular  degeneration  and  a  breaking  down  into 
cysts. 

After  microscopic  examination  of  a  number  of  diseased  ovaries, 
she  comes  to  the  following  conclusions  : — 

(1)  Cyst  formations  are  the  outcome  of  disease  ;  (2)  no  ovarian 
cyst,  small  or  large,  exists  without  a  previous  oophoritis  ;  (3)  other 
things  being  equal,  the  more  intense  the  inflammation  the  more 
rapid  is  the  growth  of  the  cyst ;  (4)  there  can  be  no  cyst  without  a 
reduction  of  the  tissue  to  protoplasm ;  (5)  this  reduction  to  proto- 
plasm is  what  we  call  inflammation ;  (6)  cysts  are  always  the  result 

*  Amer,  Jour,  of  Ohsiet.,  vol.  xvii.,  No.  4,  1800. 


PLATE   CIV. 


First  Operation  : — Right  Cystic  Ovary  removed  by  Cceliotomy  from  a 
Patient  suffering  from  Severe  Anorexia  and  Constant  Vomiting. 
"WITH  Complete  Eelief  from  the  Symptoms. 

The  left  ovary  was  reseated  at  tlie  same  time. 


PLATE    CV. 


Second  Operation  : — The  Left  Ovary  containing  Blood.  Cyst  and  Dual 
Cyst  in  the  Broad  Ligament  removed  One  Year  subsequently  to 
the  Previous  Operation,  and  for  similar  Syjiptoms,  from  the  same 
Patient.     (^See  over.) 

[To  face  1).  736. 


PLATE    CVI 


Third  Opeeation  —Uterus  and  Broad  Ligament  Cyst  of  same  Patient, 

TRO^rWHICrTHE    OVARIES  (SHO.N   IN   PeATES   CIV.,    CY.)  ^-KE   REMOVED; 

Operation  Two  Years  subsequently. 
The  cyst  A  was  found  between  the  layers  of  the  broad  ligament.     The  uterus 
was   adlnomatous,  and  the   canal,  with  the  endometrium,  presented  the 
was   aaenomaio    ,  ^^      -^^     The  hysterectomy  was  performed  for 

appearance  shown  m  tne  aiawiUj,-,   -^^     <)  [Tofacep.lBl. 

persistent  uterus  haemorrhage. 


OVARrAX  CYSTOMA.  I'M 


of  inflammation  and  are  always  accompanied  by  more  or  less  pain, 
distress,  and  disturbance  of  the  general  health. 

1.  Oophoronic  Cysts. 

a.  Simple  Cysts. — These  are  due  to  distension  of  the  Graiiffian 
follicles  of  the  ovai*y.  Occasionally  a  single  follicle  enlarges,  and 
may  attain  a  considerable  size,  but  usually  these  cysts  are  multi- 
locular  ;  a  true  unilocular  cyst,  when  large,  is  much  more  often 
paroophoronic  or  parovarian.  The  '  cystic  ovary,'  so  often  found  in 
connection  with  chronic  ovaritis,  is  an  example  of  a  simple  multi- 
locular  cyst  in  an  early  stage  of  development.  When  the  cysts  are 
still  small,  they  are  lined  with  a  single  layer  of  cubical  or  columnar 
epithelium,  which  may  be  ciliated ;  in  medium-sized  cysts  the 
epithelium  may  be  stratified  ;  but  in  the  largest  cysts  it  is  usually 
impossible  to  demonstrate  any  epithelium,  for  this  becomes  flattened 
and  finally  obliterated  by  the  increasing  intra-cystic  pressure.  The 
walls  then  appear  to  be  composed  only  of  fibrous  tissue ;  this  is  at 
first  dense,  but  as  expansion  proceeds  it  becomes  progressively 
thinner,  until  the  wall  may  give  way  under  even  gentle  manipulation. 

In  some  cases  a  single  cyst  the  size  of  a  walnut  is  found  to 
contain  blood,  or  a  blood-stained  fluid ;  the  generally  accepted  view 
is  that  this  is  due  to  haemorrhage  into  a  Graiifian  follicle  which  has 
become  converted,  without  rupture,  into  a  corpus  luteum,  for  the 
thick  wall  is  lined  by  the  yellow  and  plicated  membrane  character- 
istic of  the  corpus  luteum.  The  condition  was  formerly  known  as 
apoplexy  of  the  ovary.  Doran  has,  however,  shown  that  true 
ovarian  apoplexy  consists  of  a  haemorrhage  into  the  ovarian  stroma 
through  rupture  of  a  follicle,  and  the  term  is  now  properly  restricted 
to  this  accident. 

h.  Adenomata. — As  the  name  implies,  the  characteristic  of  these 
cysts  is  the  presence  of  glandular  elements ;  from  this  it  follows, 
first,  that  these  tumours  are  often  semi-solid ;  second,  that  as  the 
glands  are  of  the  mucous  type,  the  contents  are  usually  viscid, 
consisting  largely  of  mucin.  But  it  is  a  very  curious  feature  of 
these  adenomata  that  in  the  diflferent  loculi  several  diflferent  kinds 
of  contents  may  be  present ;  in  one  the  typical  clear  viscid  mucus, 
in  another  a  clear  limpid  fluid  ;  in  a  third  a  chocolate-coloured 
fluid,  due  to  admixture  of  blood.  The  epithelium  lining  the  loculi 
is  usually  of  the  tall  columnar  type,  the  regularity  of  the  cells 
giving  them  an  appearance  which  has  been  likened  to  a  palisade. 

3   B 


738 


DISEASES   OF   WOMEN, 


Sometimes  a  large  loculus  is  seen  to  be  surrounded  by  several  small 
ones ;  these  may  be  congregated  to  one  side  of  the  main  loculus, 
suggesting  the  '  signet-ring '  type  found  in  the  Graafian  follicle.  In 
other  cases  several  loculi  may  communicate  together,  and  this  may 

d 


Fig.  498. — Poktion  of  a  Multiloculak  Ovariax  Cyst — Adenoma — showing 
THE  Vaeieties  OF  LocxjLi.     (Bland-Sutton.) 

c,  primary ;  d,  secondary. 

occur  to  such  an  extent  that  the  cyst  appears  to  be  unilocular ;  but 
even  in  these  cases  small  loculi  may  always  be  detected  round  the 
periphery  of  the  main  cavity. '•'■ 

*  The  Etiology  of  Ovarian  Adenoma. — AValthand  has  made  an  exhaustive  ex- 
amination of  SO  ovaries  from  persons  of  various  ages,  from  new-born  infants  to  old 
women  over  sixty  }■  ears  of  age.  He  enters  most  fully  into  all  the  developmental 
relations  of  the  epithelial  elements  in  the  ovary,.and  the  histological  questions 
connected  -with  the  germ  epithelium,  the  origin  of  the  membrana  granulosa,  and 
the  formation  of  glandular  tubes  as  well  as  cysts.  Zeitscli.f.  Geb.  u.  Gyn.,  bd. 
xlix.,  ht.  2.  See  summary  by  Thomas  Wilson,  Jour.  Obstet.  and  Gyn.  Brit. 
Emf.,  July,  1903. 


OVARFAN  CYSTOMA.  739 


lu  some  adenomata  papillomatous  growths  are  found  ;  they  are 
usually  iutra-L-ystic,  aiul  there  is  reason  to  believe  that  they  owe 
their  origin  in  some  instances,  at  least,  to  the  fact  that  the 
paroophoron  is  involved  in  the  growth.  This  may  be  regarded  as 
the  explanation  more  especially  of  papillomatous  masses  arising  from 
the  deeper  parts  of  the  growth  and  invading  the  broad  ligament. 
In  rare  cases  the  papillomata  are  found  on  the  surface  of  the 
tumour,  and  these  have  been  described  as  '  surface  papilloma.' 
In  all  probability  these  growths  have  been  in  every  case  originally 
intra-cystic,  the  wall  of  the  cyst  having  thinned  out  to  such  an 
extent  that  it  has  given  way.  Surface  papillomata  are  always 
associated  with  hydroperitoneum,  and  the  papillomata  show  a  great 
tendency  to  secondary  deposition  on  other  portions  of  the  peritoneum, 
sometimes  far  distant  from  the  original  growth.  Adenomata 
associated  ^dth  papillomata  are  frequently  bilateral 

As  a  rule,  adenomata  belong  to  the  benign  type  of  tumours,  but 
not  infrequently,  and  especially  when  they  are  bilateral,  they 
present  malignant  features,  notably  in  the  form  of  secondary 
growths,  which  may  attack  the  rectum,  large  or  small  intestine, 
stomach,  duodenum,  omentum,  or  mesentery.  The  mortality  after 
operations  for  malignant  adenomata  is  very  great,  and  is  often  due 
to  the  presence  of  the  secondary  deposits,  which  may  have  given 
rise  to  no  characteristic  symptoms,  so  that  their  existence  is  not 
suspected  until  the  abdomen  is  opened.  Sometimes,  however, 
suspicion  is  aroused  by  the  co-existence  of  hydroperitoneum. 
When  this  is  found  associated  with  hydrothorax,  the  ovarian 
tumour  may  with  certainty  be  diagnosed  as  malignant,  and  opera- 
tive interference  is  contra-indicated. 

c.  Dermoids. — Cystic  tumours  are  found  arising  from  the  oophoron 
and  containing  structures  characteristic  of  mucous  membrane  or 
of  the  skin  and  its  derivati\es.  These  are  called  dermoids ;  and, 
as  the  name  implies,  only  those  tumours  containing  cutaneous 
structures  were  originally  included  in  this  group.  The  differences 
in  what  ^NTiters  understand  by  dermoids  account  for  the  varying 
statements  as  to  their  frequency,  inasmuch  as  some  writers,  as 
for  instance,  Bland-Sutton,  maintain  that  cysts  characterized  by 
mucous  membrane  should  be  classed  as  dermoids,  as  structures 
characteristic  of  these  latter  are  found  side  by  side  with  the  other 
cysts  in  the  same  tumour.  There  are  several  kinds  of  dermoids  • 
some  are  unilocular,  others  bilocular,  the  two  portions  havinif 
apparently  arisen  independently,  whilst  there   is  a  third   kind   in 


740 


DISEASES   OF   WOMEN. 


which  one  or  more  loculi  of  a  multilocular  cyst  have  dermoid  con- 
tents, the  rest  presenting  the  usual  characters  of  ovarian  adenomata. 
In  dermoids  of  the  mucous  membrane  type  tubular  or  racemose 
mucous  glands  may  be  demonstrated  on  microscopic  examination ; 
and  these  cysts  are  of  course  filled  with  mucin.  In  the  other,  and 
perhaps  even  more  remarkable,  dermoids,  we  find  such  things  as 
hair,  bone,  cartilage,  teeth,  horn,  nails,  and  mammary  glands.  The 
hair  is  generally  of  the  same  colour  as  that  of  the  woman's  head  ; 
it  may  attain  a  great  length,  and  in  dermoids  of  old  standing  it  is 
often  found  shed  and  rolled  up  in  a  ball  in  the  interior  of  the  cyst. 


Fig.  490. — An  Ovarian  Dermoid  with  a  Spurious  Mamma  and  Nipple 

GROWING   EKOM   ITS   "WalL.      (BlAND-SuTTON.) 

(Museum,  Eoyal  College  of  Surgeons.) 

Teeth  may  be  present  in  large"  numbers,  and  different  shapes ; 
molars,  incisors,  and  canines  may  be  represented.  A  mammary 
gland  is  sometimes  adorned  with  a  rudimentary  nipple ;  but  the 
substance  of  the  '  gland  '  is  made  up  of  fat,  not  of  gland  tissue.  On 
microscopic  examination  of  the  wall  of  a  dermoid  we  find  the 
histological  characters  of  true  skin,  including  sebaceous  and  sweat 
glands ;  non-striped  muscle  and  nerve  tissue  have  also  been  de- 
scribed. Besides  the  various  structures  we  have  enumerated,  the 
contents  of  a  dermoid  usually  consist  of  a  mixture  of  shed  epithelium, 
loose  hair,  and  fat  derived  from  the  sebaceous  glands;  the  whole 
forming  a  pultaceous  mass.    The  dermoid  contents  sometimes  become 


UVAIilAN  CYSTOMA.  741 


broken  up  and  rolled  into  a  great  number  of  little  balls,  the  size  of 
peas ;  these  have  been  called  epithelial  pills,  and  consist  of  epithe- 
lium fat ;  the  nucleus  may  consist  of  one  or  more  hairs.  In  a  case 
reported  by  Walter  (Manchester),  4000  of  these  little  balls  were 
found.     Dermoids  ai'e  sometimes  bilateral. 

It  is  a  curious  fact  that  among  ovarian  tumours  complicating 
pregnancy,  a  large  proportion  of  the  reported  cases  have  been  der- 
moids ;  and  the  complication  is  a  serious  one,  because,  apart  from 
the  mechanical  difficulties  which  may  arise  during  parturition,  there 
is  a  considerable  danger  of  septicjemia,  owing  to  the  tendency  of 
dermoids  to  suppurate.  At  the  same  time,  it  must  be  pointed  out 
that  in  some  cases  the  greenish  or  yellowish  contents  of  a  non- 
suppurating  dermoid  have  been  mistaken  for  pus.  Even  when  there 
is  no  question  of  pus,  the  contents  of  a  dermoid  are  apt  to  be  very 
irritating  to  the  peritoneum,  if  they  escape  into  the  peritoneal  cavity 
owing  to  the  rupture  of  a  cyst  during  extraction ;  this  accident 
fihould  therefore  always  be  avoided  if  possible,  and  the  tumour 
extracted  whole. 

A  well-formed  heart,  with  mitral  valve,  half  the  tongue,  a  hand,  the  jaw- 
bone, trachea,  and  the  eye,  have  been  found  in  dermoids  by  Johnstone 
(Cincinnati).     He  contends  that — 

'  The  ovarian  dermoid  is  a  true  parthenogenesis,  that  is,  "  that  the  ovum 
itself  is  at  fault,  and  that,  instead  of  losing  one  of  its  polar  cells,  it  retains  the 
male  element  from  some  pathological  reason  and  goes  on  in  a  weak  way  in 
an  effort  to  form  the  human  body."  If  dermoids  were  a  doubling-in  of  the 
mother's  own  membranes  we  should  expect  to  find  them  in  the  hilum  of  the 
ovary.  Such  a  thing  is  almost  unheard  of,  and  therefore  they  are  not 
the  remnants  of  the  mother's  own  fcetal  life.  The  same  pathological  process 
that  starts  the  bjqoertropbj'  of  the  ovary  which  results  in  ovarian  tumours, 
catching  many  of  the  follicles  in  different  grades  of  development,  finds  some 
of  the  ova  contained  in  these  follicles  that  have  not  lost  the  polar  cell  and 
are  still  adherent  to  the  Graafian  follicle.  This  hj'pertropbic  growth  arrests 
the  development  of  the  ovum,  holds  it  fast  to  the  cyst-wall,  and  does  not 
allow  the  little  cell  to  follow  out  its  physiological  law  and  get  rid  of  one 
element.  This  being  retained  and  receiving  food  and  nourishment,  in  an 
irregidar  way  attempts  to  follow  out  its  own  natural  history,  and  a  dermoid  is 
the  result.' 

Teratoma  Ovarii. — Backhaus  had  a  typical  case  of  this  condition.  The 
growth  occurred  in  a  girl  aged  seventeen,  being  the  size  of  a  man's  head. 

'  It  had  developed  in  the  course  of  three  years,  consisted  ciiiefly  of  solid 
tissue,  resembling  homogeneous  marrow  in  appearance,  with  cysts  containing 
cartilage,  hair,  and  teeth ;  radiogi'aphically  bony  strata  could  be  recognized. 
Microscopical  examination  showed  a  motley  confusion  of  derivatives  of  all 
three  germinal  layers  with  undefined  arrangement.     A  comparatively  large 


742  DISEASES   OF   WOMEN, 

quantity  of  embiyoual  brain  matter  was  present,  and  spots  were  noticeable 
•which  appeared  to  be  proliferating  or  ependynie  cells.  On  the  twenty-tifth 
day  after  the  first  operation  (ovariotomy  of  the  right  adnexa),  as  the  tumour 
appeared  to  be  malignant,  the  other  ovary  and  the  uterus  were  removed  by 
the  vagina  and  two  subsequent  laparotomies  were  performed  for  ileus.  After 
about  three  months  metastases  appeared  in  the  most  various  organs,  omentum, 
liver,  brain,  and  kidneys,  and  the  patient  after  five  months  died  in  her  OAvn 
home.  Backhaus  classifies  the  teratomata,  the  solid  embryomata  of  the 
ovaries,  among  malignant  new  growths.'  * 

Pick  has  shown  that  teratomata  may  contain  derivatives  of  the  membranes 
of  the  embryo,  and  in  one  case  there  was  a  hydatiform  growth  in  part  of  the 
dermoid  tumour — a  chorio-epitheliomatous  new  growth. 

In  a  case  of  Falk's  f  there  were  metastases  of  small  nodular  growths  over 
the  entire  peritoneum,  and  one  of  the  nodes  was  proved  to  contain  cysts 
lined  with  cylindrical  epithelium,  smooth  and  striated  muscular  fibres,  car- 
tilaginous materia],  skin  elements,  and  ganglion  cells. 

Dermoid  Cysts  of  the  Broad  Ligaments. — These  cysts  are  quite  independent 
of  the  ovaries ;  they  form  a  distinct  variety.  They  are  very  rare,  only  some 
ten  cases  having  as  yet  been  recorded.  Their  pathology  is  allied  to  that  of 
those  of  the  ovary  ;  their  diagnosis  is  most  difficult.  They  evolve  more 
slowly,  they  cause  more  pain,  and  are  more  sensitive  to  manipulation  than 
the  ovarian.J 

Retro-rectal  Cysts. — These  have  been  met  with  in  some  few  cases.  They 
occur  either  above  or  below  the  levator  ani,  between  the  rectum  and  coccyx, 
or  in  the  subserous  tissue  between  Douglas'  pouch  and  the  levator.  Those 
in  front  of  the  rectum  are  apt  to  be  mistaken  for  other  tumours  in  the  pouch. 
They  must  be  removed  by  an  incision  at  the  side  of  the  sacrum,  or 
perineotomy,  according  to  the  situation  of  the  cyst.§ 

Cancer  in  a  Dermoid  Cyst  of  the  Ovary. — Clark,  of  Johns  Hopkins  Hospital, 
has  recorded  a  case  of  a  combined  cystic  and  solid  tumour  of  the  left  ovary. 
Tlie  cyst  had  the  characteristic  epidermal  appearance,  and  there  was  a  growth 
of  short  black  hair.  No  teeth,  bone,  or  cartilaginous  structures  were  found, 
but  on  microscopic  examination  of  sections  taken  at  the  junction  of  the  cyst- 
wall  with  the  tumour,  cancerous  epithelial  degeneration  and  projections  were 
seen,  while  the  centre  of  the  tumour  was  almost  entirely  composed  of  cancerous 
structure. 

Tuberculosis  and  Dermoid. — Elsewhere  a  cone  of  dermoid  is  recorded  in 
which  the  tumour  was  mistaken  for  a  malignant  one,  but  operation  proved  it 
to  be  associated  with  pelvic  tuberculosis. 

2.  Paroophoronic  Cysts. 

■  These  are  developed  in  the  hilum  of  the  ovary,  and  while  they 
are  still  small,  they  can  be  distinguished  from  the  previous  vai'ieties 

*  Brit  Gyn.  Jour.,  May,  1901,  and  Munch,  m.  Wchns.,  1901,  No.  10. 

t  Monf.  Gel),  u.  Gyn.,  bd.  xii.,  ht.  3. 

X  Bertholet,  Brit   Gyn.  Jour.,  1899. 

§  Arch.f.  Klin.  Cliirurgie,  hd.  Ivii.,  lit.  1. 


PLATE    CYII. 


^ 


BeOAD   LlGAMEXT    CyST.      (J.    TaTLOK.) 

Nat.  size.     Removed  successfully  by  the  vagina. 

{Toface'p.  742. 


PLATE    CYIII. 


Cyst  of  the  Meso-salpinx,  sqiclatixg  ax  Ectopic  Gestatiox  Cyst. 
(Author.) 

PLATE   CIX. 


Paeovakian  Cyst  Lyixg  ix  Douglas's  Pouch,  simulatixg  FlEteovekstox 
ox  Uteeus.     (Authoe.)  [To  face  f.  TiS. 


OVABIAN  CYSTOMA, 


743 


by  the  fact  that  the  cortex  of  the  ovary  can  be  recognized  more  or 
less  unaltered  on  the  surface  of  the  cyst.  They  are  distinguished 
from  parovarian  cysts  (to  be  next  described),  by  the  fact  that  the 
ovary  is  involved  (Fig.  500).  When  they  attain  a  considerable  size, 
the  ovarian  tissue  may  be  very  hard  to  recognize  ;  but  they  arc  easily 
diflercntiated  from  oophoronic  cysts  by  the  following  characters ; 
they  burrow  deeply  into  the  broad  ligament,  are  unilocular,  and 
their  walls  are  frequently  lined  by  papillomatous  masses.  When 
no  papillomata  are  present,  it  may  not  be  possible  to  say  whether 
the  cyst  owes  its  origin  to  the  paroophoron  or  to  the  parovarium  ; 
but  the  presumption  will  be  in  favour  of  the  latter.     The  w^alls  of 


Fig.  500. — Ax  Ixcipiext  Oophoroxic  Cyst.    (Blaxd-Sl'ttox.) 
A,  oophoroa  ;  b,  paroophoron ;  p,  parovarium  ;  f,  fallopian  tube. 

paroophoronic  cysts  are  lined  by  a  single  layer  of  columnar  iBpi- 
thelium,  and  are  often  thin ;  consequently  they  easily  rupture, 
exposing  the  papillomatous  masses.  This  is  always  followed  by 
abundant  hydro-peritoneum,  and  the  warty  growths  show  a  great 
tendency  to  be  detached  and  transplanted  to  distant  parts  of  the 
peritoneum,  where  they  become  the  starting-point  of  fresh  growths. 
There  is,  however,  no  tendency  to  recurrence  after  removal,  and 
with  the  evacuation  of  the  fluid  from  the  peritoneal  cavity  the 
secondary  warts  disappear  from  the  peritoneum.  Paroophooronic 
cysts  are  frequently  bilateral. 

The  papillomata  are  usually  very  vascular,  and  free  haemorrhage 
may  occur  during  the  manipulations  incidental  to  their  removal. 


744 


DISEASES   OF   WOMEN. 


3.  Parovarian  Cysts. 

These  are  due  to  distension  of  the  vertical  tubes  representing  the 
remains  of  the  mesonephric  tubes  known  as  broad  ligament  cysts. 
As  they  grow  they  distend  the  layers  of  the  meso-salpinx,  and  the 
Fallopian  tube  is  found,  often  elongated,  lying  across  the  summit  of 
the  cyst  (Fig.  501).  The  ovary  of  the  same  side  can  generally  be 
distinguished  as  distinct  from  the  tumour.  In  the  case  of  very  large 
cysts,  the  ovary  may  be  so  flattened  as  to  be  almost  unrecognizable 
except  on  microscopic  section.  Parovarian  cysts  are  found  of  all 
sizes ;  small  cysts  the  size  of  a  pea  may  be  discovered  accidentally, 
when  the  abdomen  is  opened  for  other  reasons ;  but  cysts  which  are 
operated  upon  mostly  vary  in  size  between  a  large  orange  and  a 
cocoa-nut.  The  smaller  cysts  are  lined  with  ciliated  columnar 
epithelium ;  as  the  tumour  enlarges,  the  epithelium  first  becomes 
stratified,  and  then  atrophies.  The  walls  are  thin  and  translucent : 
the  contents  consist  of  a  clear  limpid  fluid,  which  throws  down  a 
flaky  precipitate  with  alcohol.  Papillomatous  masses  are  rarely  found 
in  their  interior,  and  this  serves  to  distinguish  them  from  the  paro- 
ophoronic  cysts  previously  described.  They  are  always  unilocular. 
They  occur  most  frequently  between  the  ages  of  twenty  and  forty. 

4.  Gartnerian  Cysts. 

In  foetal  life,  the  mesonephric,  or  Wolffian  duct  passes  from  the 
mesonephros  (parovarium  of  the  female")  to  the  base  of  the  bladder. 


Fig.  501. — A  Cyst  of  the  PAROVArauM,  sho^\t[xg  its  Eelatiox  to  Oyaey 

AXD    TrBE.       (BLAXD-SrTTOX.) 

A,  oophoron  ;  b,  paroophoron  :  f,  fallopian  tube. 
As  development  proceeds,  this  duct   becomes  obliterated,  leaving 


OVABIAN  CYSTOMA. 


745 


only  the  vestige  known  as  Gartner's  duct.  In  some  mammals,  such 
as  the  cow,  these  ducts  normally  remain  patent;  and  in  the  adult 
female  portions  of  the  duct  may  escape  obliteration,  and  become 
distended  with  a  clear  Huid.     Such  cysts  may  consequently  be  found 


Fig.  502. — Pakovariax  Cyst  situated  BET"nEEX  the  Aiipclla  of  the  Tube 
AND  the  Outer  End  of  the  Ovakt.     (Howaed  Kelly.) 

anywhere  along  the  original  course  of  the  duct,  that  is,  in  the  broad 
ligament  below  the  ovary,  by  the  side  of  the  uterus,  or  along  the 
lateral  wall  of  the  vagina.  They  are  seldom  larger  than  a  hen's 
egg,  but  occasionally  they  may  attain  much  greater  dimensions. 

Racemose  Cysts  of  the  Ovary. — Jayle  and  Benden*  describe  a 
rare  form  of  ovarian  cyst  characterized  by  the  presence  of  masses 
of  vesicles  varying  in  size,  containing  a  sero-albuminous  fluid, 
haemorrhage  having  occurred  into  some  of  these.  The  wall  of  the 
vesicle  contained  dense  connective  tissue.  They  were  lined  by 
different  types  of  epithelium,  but  at  the  pedicular  side  the  single 
layer  of  cells  was  continuous  with  the  germ  epithelium  of  the  ovary. 
The  authors  regard  these  vesicles  as  arising  from  the  germ  epithe- 
lium covering  the  ovary,  and  not  from  the  Graafian  follicles. 


Papillary  Cystoma. 

Olshausen  f  differentiated  the  various  types  of  papillary  cystoma, 
adenomatous  papilloma,  adeno  -  carcinomatous  papilloma,  cysto- 
adeno-papilloma  with  carcinoma  or  sarcoma.     We  may  thus  have 

*  Bev.  de  Gyn.  et  de  Chir.  Aid.,  Sept.-Oct.,  1903. 

t  Die  IcranTieiten  der  ovarien,  1877 ;  J.  W.  Williams,  Johns  Hopkins  Reports, 
vol.  iii.,  1892  ;  and  Pfannanstiel.  Arch.f.  Cryn.,  1895. 


746 


DISEASES   OF    WOMEN. 


Sb  parovarian  papillomatous  cyst,  a  hydrops  papilloma  of  the  Graafian 
follicle,  an  adenomatous  papilloma  which  may  be  either  simple  or 
of  a  pseudo-mucinous  nature,  a  papillomatous  adeno-carcinoma,  and 
a  papillomatous  adeno-sarcoma.  Howard  Kelly,  in  vol.  ii.  of  his 
'  Operative  Gynaecology,'  gives  a  most  clear  description  of  the 
etiology  and  dififerential  histology  of  the  ovarian  papillomata.  He 
draws  attention  to  the  following  points : — (a)  A  papilloma  has 
never  been  shown  to  have  changed  into  a  carcinoma.  (&)  The 
method  of  invasion  of  carcinoma  has  nothing  in  common  with  that 
of  papilloma,  (c)  The  latter  frequently  causes  extensive  ascites, 
and  is  apt  to  be  distributed  and  implanted  as  new  foci  throughout 
the  peritoneal  cavity.  (d)  Metastases,  in  the  true  sense  of  the 
term,  are  rare  in  the  instance  of  papilloma.  Cases  of  papilloma, 
when  the  diseased  masses  have  been  removed,  even  though  implan- 
tation had  occurred  into  the  peritoneal  cavity,  have  survived  for 
years,  (e)  Papillomata  frequently  have  a  slow  growth.  (/)  No 
anatomical  distinction  can  be  drawn  between  those  papillomata  on 

the  surface  of  the  ovary  and , 
those  occurring  in  its  interior. 
On  the  other  hand,  follicular 
papillomata  may  sprout 
through  the  walls  of  the  folli- 
cles and  thus  come  to  be  super- 
ficial. 

An  ovarian  papilloma  com- 
mences by  a  proliferation  of 
the  epithelium,  with  connec- 
tive tissue  development,  the 
latter  sustaining  the  former. 
'  It  begins,'  sajs  Kelly,  '  by  a 
proliferation  of  the  epithelium, 
and  as  this  pushes  out  from 
the  surface,  and  then  branches 
and  branches  again,  the  con- 
nective tissue  follows  it,  lying 
beneath  the  surface,  and  carry- 
ing the  blood  and  lymph  ves- 
sels. ...  The  appearance  of  a 
papilloma  is,  in  fact,  in  cross 
section,  that  of  a  tissue  interpenetrated  by  glands.'  In  other  cases, 
in  which  the  connective  tissue  elements  are  in  excess  of  the  epithelium. 


Fig.  503. — Cysto-papilloma  of  the 
ovaey.    (oullen.) 

Half  of  tumour.  Spriuging  from  its 
outer  surface  are  papillary  masses. 
They  also  project  from  the  inner  sur- 
faces of  the  cysts.  (Two  -  thirds 
natural  size.) 


nr.lh'/AX    CYSTOMA. 


747 


'^i--^?^yus 


->^>!->,_-?  <^^ 


Fig.  .")U4, 


-Papillary  Ovakiax  Cystoma. 

(AtTHOli.) 


there  is  a  greater  abuiKlance  of  bloodvessels,  these  smaller  masses 
being  barely  covered  by  epithelium  and  approaching  the  nature 
of  papillary  fibromata. 
The  diagnostic  points 
are  not  very  well  de- 
fined. Bilateral  and 
irregular  cystic  masses, 
hard,  adherent,  and 
fixed,  and  accompanied 
by  ascitic  fluid,  may 
cause  us  to  suspect 
that  a  given  mass  is 
papillomatous,  and  an 
examination  by  the  rec- 
tum may  help  to  confirm 
this.  The  hardness  of 
the  tumours  and  the 
presence  of  ascites,  to- 
gether with  other  symp- 
toms of  cachexia  and  in- 
creasing loss  of  weight,  may  make  us  suspicious  of  malignant  ovarian 
disease,  but  further  than  that  it  is  of  a  malignant  nature  we  cannot  go. 
Papillary  parovarian  cysts  are  comparatively  rare.  Pfannanstiel 
found  only  three  in  forty-eight  cases  of  papillomata.  Their  contents 
are  mainly  fluid,  and  the  papillomatous  masses  are  neither  large  nor 
numerous.  Ciliated  epithelium  is  found  inside  the  cyst.  The  folli- 
cular cysts  (Graafian)  are  not  malignant.  In  the  pseudo-mucinous 
group  there  are  multilocular  cysts  containing  pseudo-muciiie,  vary- 
ing in  consistence  and  in  the  character  of  the  secretion.  They  are 
generally  pediculated  and  generally  grow  in  pairs.  Their  growth 
is  slow,  their  nature  benign,  and  the  papillomatous  growths  are 
principally  found  in  the  cystic  spaces  and  near  the  pedicle.  In  the 
papillary  adenomata  we  find  ciliated  epithelium,  though  this  is  not 
universal  throughout  the  tumour.  Among  papillomatous  tumours 
this  form  is  rather  common.  They  are  frequently  bilateral,  and  do 
not,  as  a  rule,  attain  to  a  large  size,  the  average  maximum  being 
that  of  a  closed  fist.  The  cystomatous  variety  often  grows  to  a 
fairly  large  size,  the  contained  fluid  being  of  a  serous  character 
without  mucine.  They  are  frequently  pediculated,  while  others 
grow  between  the  folds  of  the  broad  ligament.  If  thoroughly 
extirpated  they  do  not  recur. 


748  DISEASES   OF   WOMEN. 

In  the  adeno-carcinomatous  variety,  the  growths  are  mainly 
cystic,  the  cyst  partaking  of  the  nature  of  a  cysto-carcinoma  or 
papilloma.  Carcinomatous  nodules  are  often  present  in  tlie  wall  of 
the  cyst,  the  tumour  being  either  mono-  or  poly-cystic.  In  this 
variety  metastases  are  more  common.  In  a  case  of  Kelly's  there 
was  the  same  condition  present  as  in  Gelston  Atkins'  case  *  (Plate 
ex.),  namely,  double  ovarian  papillary  cysto-carcinomata,  associated 
with  carcinoma  of  the  cervix.  As  we  might  expect,  peritoneal 
infections  of  a  malignant  nature,  and  the  formation  of  adeno- 
carcinomatous  growths,  are  not  uncommon.  The  malignancy  of 
these  tumours  is  marked,  and  the  time  of  survival  after  operation  is 
short.  Papillary  cysto-acleno-sarcoma  appears  to  be  A^ery  rare,  Kelly 
meeting  with  only  one  case,  and  Pfannenstiel  one.  In  the  latter's 
case  there  was  no  traceable  connection  between  the  papillomata 
and  the  sarcoma.  The  vascular  connective  tissue  was  interpene- 
trated with  round  and  spindle  cells. 

Ovarian  Tumours  and  Pregnancy.f 

Though  not  a  common  complication,  ovarian  tumours  occur 
sufficiently  often  during  pregnancy  to  demand  a  special  notice. 
The  presence  of  the  ov-arian  cystoma,  or  solid  tumour,  in  the  case 
of  those  cysts  which  are  not  bound  down  in  the  pelvis,  may  not  be 
noticed  until  the  pregnancy  has  advanced  for  some  months.  This 
is  the  more  likely  to  occur  if  there  are  no  adhesions  which  obstruct 
the  upward  movement  of  the  tumour,  or  adhesions  which  connect 
it  with  the  uterus  and  the  pelvic  viscera.  More  generally,  how- 
ever, attention  is  directed  to  it  either  by  the  unusual  size  and 
appearance  of  the  abdomen,  or  by  symptoms  due  to  twisting  of  the 
pedicle,  that  not  infrequently  causes  some  degree  of  peritonitis. 

So  far  as  interference  is  concerned,  the  decision  will  largely 
depend  upon  the  time  of  pregnancy  at  which  the  tumour  is  dis- 
covered, its  size,  and  probable  effect  on  the  life  of  the  mother  or 
the  child;  for  there  can  be  no  doubt  that  statistics  have  proved 
that  the  complication  of  pregnancy  with  ovarian  tumour  is  a  very 
grave  one,  and  must,  with  rare  exceptions,  be  dealt  with  by 
operation.  Dsirne,  from  the  study  of  a  hundred  and  thirty-five 
cases,  arrived  at  the  following  conclusions : — 

1.  The  further  pregnancy  progresses,  the  more  dangerous  is  the  situation 
for  mother  and  foetus. 

*  Brit.  6yn.  Jour.,  May,  1904.  f  See  also  p.  765. 


PLATE    CXI. 


C'TSTO-CARCrN'ulIA   UF    THE    OVAET. 

Interior  of  carcinomatons  ovary,  removed  with  the  other  ovary  and  two  large 
pedunculated  myomata.     Patient  survived  one  year. 

[To  face  p.  748. 


PLATE    CXTI. 


Intepjoe  of  Cysto-cakcixomatous  Ovaet. 
Eemoved  from  same  patient  as  Plate  CXI.     Q  nat.  size.) 

[To /flee  p.  749. 


OVAHIAN  CYSTOMA.  740 


.    2,  The  puncture  of  ovarian  C5'sts  and  the  prorluction  of  abortion  are  to  be 
considered  only  in  emergency. 

3.  Ovariotomy  gives  the  best  results  for  the  mother  in  the  second,  third, 
and  fourth  months  of  pregnancy  ;  for  the  product  of  conception  in  the  third 
and  fomtli. 

4.  If  an  early  ovariotomy  be  not  possible  from  various  reasons,  it  is  to  be 
can-ied  out  in  the  later  months  of  pregnancy,  as  good  results  can  even  then 
be  expected.* 

Heiberg,  from  the  statistics  of  two  hundred  and  seventy-oue 
cases  not  interfered  with,  found  that  one-fourth  of  the  mothers 
succumbed  and  two-thirds  of  the  children.  On  the  other  hand, 
the  results  in  a  hundred  and  eighty-five  cases,  collected  by  Weiss, 
Dsirne,  and  Mainzer,  which  were  operated  upon,  show  a  mortality 
of  from  six  to  seven  per  cent.t 

Thus  we  see  that,  save  in  the  case  of  parovarian  cysts,  which 
may  be  emptied  through  the  vagina  by  tapping,  the  course  to 
pursue  is  to  remove  the  ovarian  tumour  at  the  earliest  possible  date 
of  the  pregnancy.  Still,  if  the  tumour  be  not  discovered  until  very 
late  in  the  gestation,  or  if  labour  be  approaching,  it  should  be  dealt 
with  by  paracentesis. 

In  operating  on  all  ovarian  tumours  during  pregnancy,  the 
points  to  be  remembered  are — ■ 

(a)  Care,  in  making  the  abdominal  incision,  not  to  wound  the 
uterus ;  (h)  to  interfere  with  the  uterus  as  little  as  possible ;  (c)  to 
take  pains  to  tie  the  vessels  in  two  places,  and  separately  and  not 
en  masse,  remembering  the  special  danger  of  haemorrhage. 


Parotitis  following  Pelvic  Operations.; 

The  not  uncommon  occurrence  of  parotitis  following  pelvic  operations  is 
worthy  of  special  notice.  Morley  of  Michigan  §  collected  the  particulars  of 
fiftj^-one  cases,  forty-four  female  and  seven  male.  Twenty-eight  of  these 
occurred  after  ovariotomy,  and  twenty-three  after  various  other  operations 
on  the  pelvic  viscera.  In  thirty-two  instances  the  affection  set  in  from  the 
third  to  the  seventh  day.  In  a  case  of  mine,  as  in  two  recorded  by  Bumm 
and  Morricke,  the  symptoms  did  not  show  themselves  until  the  fourteenth 
day.    Suppuration  did  not  occur  in  thirty-one  cases.    There  were  thirty-eiglit 

*  Archiv.  /.  Gyn.,  No.  24. 

t  Cent./.  Gyn.,  No.  26,  1882  ;  Beitr.  Chir.  Testscl:r.  Th.  Bllrootli,  Munch.  Med. 
Woch.,  No.  48. 

X  Paper  by  author  on  '  The  Inii)oitance  of  Attention  to  the  ^[outh  and  Teeth 
before  and  after  Operations  on  the  Pelvic  Viscera,'  Brit.  Gyn.  Jour.,  May,  \Wd. 

§  Amer.  Gyn.,  1002. 


750  DISEASES   OF   WOMEN. 

recoveries.  '  Pus  was  present  in  nine,  and  absent  in  four,  of  the  thirteen  fatal 
cases.  Morley  refers  to  the  two  views  of  the  causation  of  parotitis,  V\%.  the 
correlation  due  to  a  sj'mpathetic  excitation  conveyed  through  the  sympathetic 
system  to  the  parotid,  or  to  toxins  conveyed  to  the  gland  from  the  pelvic 
viscera  through  the  lymph  and  blood  channels.  Stephen  Paget,  who  has 
collected  the  particulars  of  over  one  hundred  cases,  advocated  the  neural 
origin  of  the  affection.  But  then  this  neural  theory  is  at  the  best  un- 
satisfactory. 

In  the  communication  made  by  the  author  to  the  Gynaecological  Society, 
cases  were  instanced  in  which  the  parotitis  had  unquestionably  a  dental  origin 
(I  have  had  one  other  such  case  since),  and  the  anatomical  sources  of  the 
direct  infection  from  the  mouth  and  teeth  were  discussed  by  me,  and  the 
necessity  for  inspection  of  the  mouth  and  teeth  before  operations  on  the 
pelvic  viscera  insisted  on.  In  certain  cases  after  abdominal  operations, 
the  breath,  either  from  the  anaesthetic  or  other  cause,  often  becomes  rapidly 
foul,  and  the  mouth  impure,  with  an  enormous  increase  in  the  pathogenic 
organisms  which  are  naturally  present  in  the  buccal  cavity.  If,  in  addition, 
there  be  carious  teeth  present,  or  the  patient  be  suffering  from  pyorrlima 
alveolaris,  with  pus  pockets  between  the  alveoli  and  the  roots  of  the  teeth, 
the  condition  is  further  complicated  by  a  gingivitis,  accompanied  by  strepto- 
coccus invasion  and  an  increase  in  putrefactive  organisms.  Such  a  condition 
is  well  calculated  to  originate  gastric  fermentation,  and  initiate  processes  which 
are  the  result  of  the  absorbed  toxins  generated  in  the  mouth.  Quite  inde- 
pendent, then,  of  any  increased  risk  of  parotid  infection,  it  is  well  to  attend 
to  the  mouth  and  teeth  both  before  and  for  the  first  days  after  a  pelvic  or 
abdominal  operation. 

The  disinfectants  which  I  have  been  in  the  habit  of  using  for  the  mouth 
after  operations  are  permanganate  of  potash,  formalin,  peroxide  of  hydrogen, 
boracic  acid,  and  sulphurous  acid,  'i  he  one  I  prefer  is  a  combination  of  boric 
acid,  formalin,  and  glycothymolin,  or  formalyptol.  The  last-named  preparation 
is  a  very  pleasant  disinfectant,  forming  a  useful  basis  for  the  others  I  have 
mentioned.  In  the  gastric  complications  in  which  this  foetor  of  the  mouth 
and  breath  is  present,  benzonaphthol,  given  in  the  form  of  cachets,  I  have 
found  most  useful,  and  likewise  a  periodical  small  dose  of  calomel  as  au 
intestinal  disinfectant. 


CHAPTER   XXXIX. 

OVARIAN    CYSTOMA—DIAGNOSIS    AND 
TREATMENT. 

That  surgeon  has  the  least  chance  of  committing  an  error  in  his 
diagnosis  of  an  abdominal  tumour  who  commences  his  examination 
of  the  case  by  recollecting  the  many  possible  and  likely  sources  of 
error  which  he  has  to  avoid.  Gaillard  Thomas  collated  a  list  of 
forty-three  diseased  conditions  which  may  be  mistaken  for  ovarian 
cystoma.  It  must  also  be  remembered  that  it  is  not  in  the  well- 
marked  case  of  ovarian  cystic  disease  that  the  careful  surgeon  is 
apt  to  fall  into  error.  Rather  is  it  when  he  is  confronted  by  a  case 
in  which  some  obscure  and  unfamiliar  signs  are  present,  and  when 
the  history  of  the  growth  of  the  tumour  is  not  clear,  or  evident 
complications  exist,  such,  for  example,  as  pregnancy,  great  obesity, 
ascites,  or  cystic  degeneration  of  any  of  the  abdominal  viscera.  Inde- 
pendently of  the  nature  of  the  tumour,  there  are  other  points  which 
he  has  to  decide,  and  which  are  of  vital  moment  to  the  woman.  Such 
are,  its  benign  or  malignant  character,  the  presence  of  adhesions, 
the  amount  and  the  position  of  the  solid  matter  present,  the  general 
constitutional  state  of  the  patient,  and  the  evidence  of  any  grave 
aflfection  of  the  lungs,  heart,  kidney,  liver,  spleen,  bowel,  or  uterus, 
which  may  complicate  the  operation  of  ovariotomy,  and  contra- 
indicate  its  performance.  Overweening  self-confidence  will  nowhere 
more  startlingly  meet  the  rebuff  it  merits  than  in  the  case  of  over- 
confident diagnosis  of  abdominal  tumours.  The  egotism  and  egoism 
of  the  medical  Society's  debate  often  finds  a  strange  and  conflicting 
humiliation  through  the  medium  of  the  operating  knife. 

It  may  be  well  to  enumerate  those  conditions  which  we  are  liable 
to  confound  with  OA^arian  cystic  disease : — 

Great  obesity.  I  Distended  bladder. 

Hysterical  tympanites  and  phantom  j  Hydrometra. 

tumour  (pseudocyesis).  I  Hsematometra. 

Faecal  tumour.  \  Pyometra. 

Dilation  of  the  stomach.  Pbvsometra. 


752 


DISEASES   OF   WOMEN, 


Hydro-salpinx. 

Ascites.* 

Encysted  dropsy. 

Hsematocele. 

Cystic  disease  of  the  parovarium. 

„  „         kidney. 

„  „         spleen. 

„  „        liver. 

,,  „         uterus. 

Uterine  fibromyoma. 
Enlargements  and  displacements   of 

the  liver,  spleen,  and  kidney. 
Hj^droneplirosis  and  pyonephrosis. 
Disease  of  the  abdominal  glands. 


Omental  tumour. 

Pregnancy. 

Ectopic  gestation. 

Hydramnios. 

Death  of  foetus. 

Pelvic  abscess. 

Hydatid  mole. 

Accumulation  of  pus  or  serum  in  the 

peritoneal  cavity. 
Malignant  disease  of  the  uterus. 

,,  ,,  ,,      peritoneum. 

Extra-peritoneal  cysts  (Tait). 
Mesenteric  lipoma,  or  chyle  cyst. 


Nearly  all  these  conditions  I  have  myself  known,  at  one  time 

or    another,    mistaken    for 
ovarian  tumour. 

Examination  of  a  Sus- 
pected Case  of  Ovarian 
Cystoma. 

The  directions  given 
(Chap.  II.)  as  to  the  steps 
which  must  be  followed  in 
completing  a  diagnosis,  and 
the  appliances  necessary  to 
conduct  such  examination, 
should  be  referred  to.  Be- 
fore classifying  the  positive 
and  negative  signs  on  which 
we  rely  in  arriving  at  a 
diagnosis,  it  may  be  well  to 
refer  to  the  most  important 
facts  in  the  history  of  an 
ovarian  growth  which  assist 
in  diagnosis. 

History  and  Early  Symp- 
toms.— Early  operative 
treatment   in   all    forms  of 


Fig. 


50.5.— OvAEiAN  Tumour  compressixo 
Thorax.    (Spexcee  Wells.) 


ovarian  cystic  disease  has  made  a  great  difference  in  the  number 

*  Demons  has  shown  the  frequent  occurrence  of  ascites  with  both  ovarian 
tumours  and  broad  ligament  cysts  {8em.  Med.,  1902,  No.  44). 


OVAJ^f.W   CVSTO.\fA—l>TA<iSOSIS  AXD    THE  ATM  EST. 


IWA 


of  women  now  suffering  from  large  ovarian  tumours.  Such  tumours 
are  rather  the  exception  than  the  rule,  and  hence  the  charac- 
teristic signs  and  symptoms  of  "  ovarian  dropsy "  are  not  so 
frequently  met  with.  The  tumour  has  usually  commenced  at  one 
side,  and  has  at  first  caused  but  little  distress.  This,  however, 
is  by  no  means  an  absolute  rule.  There  may  be  dysmenorrhoea, 
pelvic  and  reflex  pains,  and,  while  the  tumour  is  stUl  pelvic,  irrita- 
bility of  the  bladder  and  rectum,  Htemorrhoids  may  form  from 
pressure.  All  these  early  symptoms  are  aggravated  if  the  cyst-wall 
contract  adhesions,  and  if  the  tumour  be  prevented  from  rising  into 
the  abdominal  cavity.  The  general  health  is  at  first  but  little  inter- 
fered with.  There  is  no  oedema  of  the  upper  or  lower  extremities. 
There  is  not  much  to  rely  on  with  regard  to  the  menstrual  periods^ 


Fig.  .50H.— Ovamax  Cystoma.    (Bright.) 

and  menstruation  may  not  be  interrupted.  Occasionally  there  is 
even  menorrhagia ;  or,  on  the  other  hand,  the  flow  may  become  in 
the  first  instance  scanty,  and  finally  cease.  The  breasts  may  slightly 
enlarge,  and  the  characteristic  appearances  of  early  pregnancy  (with 
the  exception  of  the  secretion  of  milk)  may  be  present. 

Prolonged  lactation  has  to  be  remembered.  A  patient  miscarried  six 
years  before  I  saw  her.  The  breasts  still  secreted  milk,  and  the  flow  was 
increased  at  the  menstrual  advent. 

Obscure  peritoneal  pains  are  sometimes  complained  of — the  result 
of  distension  or  stretching  of  the  peritoneum,  or  twisting  of  the 
pedicle.     Nausea  and  vomiting  occasionally  accompany  such  pains. 

The  growth  may  still  be  distinctly  asymmetrical  after  the  tumour 
rises  above  the  pelvis,  but  gradually  it  assumes  a  central  position. 

3  c 


754 


DISEASES   OF    WOMEN. 


There  is  not  any  regularity  in  the  rate  of  growth.  Some  tumours 
may  increase  very  slowly,  or  remain  quiescent  for  a  time  ;  others 
develop  with  extraordinary  rapidity^  each' week  producing  a  marked 


Fig.  .508. — A  PArxcHED  Abdomen  cox- 

TAIXIXG    NEITHER    FlEID    XOE    TuMOEE, 

but  closely  eesemblixg  ax  ov.^^jjiax 
Cyst. 


ffl 

\  i  \\ 

Fig.  507. — Laege  Polycystic 
OvAEiAX  TuMorE,  IX  ax  ex- 
cessively Fat  Patiext. 

The  great  distension  of  the 
upper  abdominal  zone  is  evi- 
dent and  characteristic  of  the 
obese. 

chancre  in  the  shape  and  size  of  the  abdomen.  The  growth  may  now 
be  attended  with  abdominal  tenderness  in  parts,  or  peritoneal  pain, 
while  the  pelvic  symptoms  are  relieved.  The  countenance  gradually 
begins  to  change.  Confinement,  anxiety,  suffering,  emaciation,  tell 
in  the  expression  of  the  face. 


Fig.  509. — Veetical  Oetlixtes  or  a  Fig.  510. — Xodtjlae  Outlines  of  a 

MY03IATOU3    UtEEUS.  LaEGE   FIBROCYSTIC   TuMOUE. 

OuTLixE  Deawisgs  OF  Abdojiinal  Exlaegejiexts  feom  Photogeaphs  by 
Howaed  Kelly. 


oVAIifAN   CV!iTnM A— DIAGNOSIS   AXI>    TIIEATMENT.  T.lo 

"Wells  thus  graphically  closcribes  the  '  facies  ovariana : '  '  The 
emaciation,  the ;  prominent,  almost  uncovered  bones,  the  expres- 
sion of  anxiety  and  suft'ering,  the  furrowed  forehead,  the  sunken 
eyes,  the  open,  sharply  defined  nostrils,  the  long,  compressed 
lips,  the  depressed  angles  of  the  mouth,  and  the  deep  wrinkles 
curving  round  these  angles,  form  a  face  which  is  strikingly  charac- 
teristic' Should  relief  not  come  by  operative  means,  the  abdominal 
distension  increases,  the  superficial  veins  may  become  enlarged, 
linefe  albicautes  appear,  constitutional  symptoms,  both  thoracic 
and  abdominal,  being  aggravated  by  the  increasing  pressure,  the 
patient  finally  sinking  from  the  combined  effects  of  emaciation  and 
organic  disease  induced  in  the  heart,  lungs,  stomach,  or  kidneys. 

Hydramnios. — It  is  important  to  remember  the  chance  of  the 
surgeon  mistaking  hydramnios  for  ovarian  cystoma.  The  difficulty 
in  diagnosis  consists  in  the  absence  of  some  of  the  signs  of  pregnancy 
in  the  instance  of  hydramnios. 

The  following  is  a  case  in  point  : — 

Hydramnios  and  Ascites. — In  the  early  years  of  my  career  I  went  prepared 
to  tap  a  patient  for  ascites  in  whom  most  urgent  symptoms  of  dyspnoea  and 
lung  complication  threatened  life.  There  was  albumen  in  the  urine,  and 
great  cedema  of  the  lower  extremities.  Before  finally  puncturing  the 
abdominal  wall,  I  passed  the  uterine  sound,  and  discovered  the  enlarged 
uterus.  There  was  an  escape  of  an  enormous  quantity  of  amniotic  fluid. 
The  patient  was  dehvered  within  twenty-four  hours  of  a  healthy  child. 

Ovarian  Cysto-Sarcoma  and  Ascites. — In  the  case  of  a  multilocular  cysto- 
sarcomatous  tumour,  removed  by  me  from  a  girl  aged  twenty,  the  diagnosis 
was  obscured  by  the  presence  of  a  large  quantity  of  ascitic  fluid,  which  dis- 
tended the  abdomen.  It  was  found  on  removal  of  this  tumour  that  a  few  of 
the  superficial  cysts  had  ruptured,  and  this  explained  the  ascites,  which  could 
not  be  accounted  for  before  operation,  all  the  viscera  being  healthy.  She 
had  been  twice  tapped.  On  drawing  off  some  of  the  fluid  prior  to  operation 
for  the  purpose  of  diagnosis,  it  was  discovered  to  contain  some  slight  traces 
of  paralbumen,  and  yet  it  did  not  spontaneously  coagulate,  as  ascitic  fluid 
would.  A  few  of  Drysdale's  granular  cells  were  found  in  different  portions 
of  the  fluid  examined.  The  operation  proved  the  fluid  to  be  in  gi-eater  part 
ascitic,  the  few  cysts  which  had  burst  on  the  surface  of  the  cystoma  not  being 
larger  in  size  than  a  hen's  Qgg. 

The  liabflity  to  err  in  the  presence  of  a  quantity  of  ascitic  fluid  was  well 
illustrated  by  a  case  recorded  by  Walter  (Manchester).  There  had  been  a 
suspicion  of  pregnancy  in  consequence  of  coitus  and  suppression  of  catamenia. 
The  signs  of  pregnancy  were  absent,  and  hard,  irregular  masses  were  felt  in 
the  umbilical  region.  The  presence  of  these  masses,  together  with  rapid  enlarge- 
ment of  the  abdomen,  and  no  symptoms  of  tubercular  disease,  pointed  to 
some  mahgnant  condition  difficult  to  determine.  A  multilocular  cystoma  was 
discovered,  which  had  ruptured  and  caused  the  ascitic  accumulation. 


756 


DISEASES   OF   WOMEN. 


Cases  illustrative  of  Difficulty  in  Diagnosis. 

To  illustrate  the  difficulty  of  diagnosis  in  some  cases  of  cystic 
tumour  of  the  ovary,  I  may  cite  the  following  cases  : — 


Large  Semi-solid  Cysto-Sarcoma  of  the  Ovary.* 

A  large  tumour  in  a  patient  aged  40  had  been  diagnosed  by  another 
surgeon  as  a  fibroid  of  the  uterus.  The  mass  had  a  very  solid  feeling  on 
palpation,  and  fluctuation  was  with  difficulty  detected.  The  tumour,  on 
careful  examination,  seemed  to  be  distinct  from  the  uterus,  the  cavity  of 
which  did  not  exceed  three  inches  in  length.  It  filled  the  right  hypochon- 
drium,  the  epigastrium,  and  the  left  hypochondrium.  In  these  regions,  and 
above  the  level  of  the  umbilicus,  it  was  distinctly  solid.  It  was  most  difficult 
to  isolate  it  from  the  liver  and  spleen.  The  conclusion  arrived  at  was  that 
the  tumour  was  a  multilocular  ovarian,  and  that  it  was  in  gi-eat  part  solid. 
How  far  it  was  adherent,  or  to  what  extent  the  adjacent  viscera  were  involved, 


Fig.  511. — Solid  Multiloculak  Ovaeiax  Cysto-Saecoma.    (At;thok.) 

One  side  of  the  inverted  cyst,  X — X,  marks  the  limit  of  the  solid  portion  of  the 
growth.  The  solid  mass  proved  to  be  a  sarcoma — 12  inches  in  the  trans- 
verse by  10  inches  in  the  vertical  measurement. 

it  was  not  possible  to  say.  Operation  proved  that  the  diagnosis  was  correct. 
The  parietal  peritoneal  adhesions  were  easily  detached,  but  great  difficulty 
was  experienced  in  removing  the  tumour.  It  was  impossible  to  get  it  through 
a  rather  extensive  incision.  Most  of  the  cysts  were  emptied  with  the  trocar. 
About  nine  pints  of  liquid  were  dravra  off  without  apparently  diminishing 

"  *  See  Plate  OXIV.,  p.  772.  ' 


PLATE   CXIII. 


Solid  Otaeiax  Adenoma  with  Cystosia,  eemoved  immediately  aftek 
AX  Acute  Attack  ov  General  Peeitonitis.     (Author.) 

Pathological  Report :  '  A  multilocular  ovarian  cyst,  consisting  cliiefly  of  one 
large  loculus,  with  imperfect  septa.  The  whole  specimen  (after  evacuation 
of  the  cystic  fluid)  is  about  the  size  of  an  adult  head.  The  pedicle  appears 
to  have  been  twisted,  and  the  surface  of  the  specimen  was  universally 
adherent.  The  meso-salpinx  is  j^lasterpd  to  the  cyst-wall,  but  the 
Fallopian  tube  in  it  is  normal.  The  solid  portion  of  this  specimen  has 
the  structure  of  a  simple  multilocular  adenoma  of  the  ovary.  The  smaller 
sjjaces  are  lined  with  columnar  epithelium,  and  the  larger  ones  are  filled 
with  a  colloid  substance.  There  is  no  evidence  of  malignant  disease.' 
(J.  H.  Targett.) 

[  To  face  p.  7.57. 


OVABIAX  CYSTOMA— DIAGNOSIS  AND    TREATMENT.  757 

much  the  bulk  of  the  tumour.  The  incision  in  the  cyst-wall  was  enlarged, 
and  the  inside  of  the  cyst  was  gi'asped  with  the  hand,  and  thus  the  inverted 
mass  was  delivered.     The  patient  made  an  excellent  recovery. 

Adenomatous  and  Cystic  Ovary  removed  immediately  after  an 
Attack  of  General  Peritonitis. 

The  tumour  shown  in  Plate  (CXIII.)  was  removed  from  a  patient 
aged  46.  She  had  just  passed  through  a  sharp  attack  of  peritonitis, 
to  which  she  had  nearly  succumbed,  the  temperature  rising  to 
105^,  with  great  distension  of  the  abdomen.  Dr.  Disney  had  been 
summoned  in  the  first  instance,  as  the  patient  believed  herself 
pregnant,  and  thought  the  pains  were  those  of  labour.  Before 
operation  the  abdomen  was  greatly  swollen ;  there  was  great  pain 
and  sensitiveness  to  touch.     The  pulse  was  rapid  and  feeble. 

On  opening  the  abdomen  a  quantity  of  ascitic  fluid  escaped,  and 
the  parietal  peritoneum  was  found  completely  adherent  to  the  large 
cyst-wall — this  was  so  to  its  entire  extent.  It  was  carefidly 
detached  all  round  before  using  the  trocar,  and  when  the  cyst  had 
collapsed  the  bowel  was  found  in  several  places  adherent  in  festoons 
to  the  posterior  surface  of  its  walls ;  considerable  loops  of  intestine 
were  attached,  and  these  had  to  be  carefully  peeled  off,  the 
vessels  where  necessary  being  ligatured.  A  drainage  tube  was 
inserted.  The  patient  went  to  the  seaside  on  the  twenty-fifth  day 
from  the  date  of  operation. 

The  recent  attack  of  severe  general  peritonitis,  the  universal 
adhesions,  and  extensive  bowel  attachments,  and  the  importance 
of  rapid  operation  before  these  adhesions  had  become  stronger, 
were  the  principal  points  of  interest. 

Suppurating  Cystoma. 

Large   Puerperal   Suppurated   Ovarian  Cystoma  with   Extensive 
Adhesions  to  the  Bowel  and  Omentum. 

The  patient  was  confined  fom-  weeks  before  the  operation.  The  delivery 
had  been  followed  within  forty-eight  hours  by  an  elevation  of  temperature, 
and  the  abdomen  was  then  swollen,  and  appeared  to  contain  fluid.  The 
temperature  remained  erratic,  and  varied  in  range  between  102^  and  105°. 
Dr,  Allen  of  Stanmore  assisted  me  at  the  operation.  The  cyst-wall  was 
greatly  thickened,  closely  adherent  to  the  entire  parietal  peritoneum,  which 
had  to  be  peeled  off  at  both  sides,  after  the  cyst  had  been  tapped  and 
syphoned  of  pus.  The  approach  to  a  very  broad  pecUcIe  was  most  difficult ; 
it  was  buried  in  adhesions  formed  between  the  rectum  at  the  left  side 
and  the  sac  and  a  greatly  enlarged  Fallopian  tube.     It  was  secured  in  three 


758  DISEASES   OF   WOMEN. 

portions  and  divided,  and  then  came  the  most  difficult  part  of  the  operation. 
The  sac  was  firmly  adherent  posteriorly  all  over  its  surface  to  the  bowel ; 
the  colon  and  the  meso-colon  were  plastered  to  it  above,  with  the  omentum, 
requiring  the  greatest  care  in  separation,  and  causing  considerable  difficulty 
in  the  arrest  of  bleeding.  However,  the  sac  was  finally  removed  in  its 
entirety,  all  bleeding  was  arrested,  and  the  abdominal  and  pelvic  cavities  were 
left  perfectly  clean.  The  patient  suffered  from  no  shock,  and  made  a  good 
recovery. 

Suppurating  Ovarian  Cystoma  complicating  Induced  Abortion  in  the  Third 
Month. — A  primipara,  aged  35,  had  aborted  fourteen  days  previously  to  my 
seeing  her  (the  abortion  was  induced).  Five  days  previously,  pain  and 
vomiting  set  in,  with  difficulty  in  micturition.  The  vomiting  became  in- 
cessant, and  when  seen  by  me  the  temperature  was  104°,  the  pulse  rajjid 
and  feeble.  The  abdomen  was  considerably  swollen  and  tender  to  the 
touch;  the  suprapubic  area  was  dull  on  percussion,  and  resistant.  On 
examination,  the  uterus  was  found  fixed,  the  os  uteri  not  patulous,  and  a 
considerable  swelling  in  the  utero-vesical  space.  There  was  no  discharge. 
Notwithstanding  active  treatment,  the  symptoms  continued  with  but  slight 
abatement  until  the  eighth  day.  The  vaginal  swelling  then  softened,  and 
fluctuation  was  detected.  The  midwife  who  attended  her  was  positive  that  the 
ovum  and  membranes  had  completely  come  away,  and  nothing  was  discovered 
in  the  uterus  after  dilatation  and  exploration.  Abdominal  coeliotomy  was 
performed  on  the  eleventh  day  from  the  onset  of  her  symptoms.  On  opening 
the  abdomen  a  cyst  was  found  reaching  to  the  umbihcus,  having  extensive 
adhesions  to  the  peritoneum  all  over  its  anterior  wall.  Loops  of  the  bowel 
were  also  adherent  in  parts.  In  the  severing  of  the  adhesions  the  cyst  burst, 
and  a  large  quantity  of  pus  escaped.  It  was  an  ovarian  cyst  growing  from 
the  left  ovary.  The  condition  of  the  patient  during  the  operation  was  most 
critical.  The  abdomen  was  flushed  out  with  weak  formalin  solution,  and  the 
pelvis  was  thoroughly  mopped  with  the  same.  On  the  third  day  from  the 
operation  she  was  delirious,  her  pulse  140°,  her  temperature  101°.  She  then 
became  unconscious,  and  remained  in  this  condition  for  over  twenty-four 
hours.  However,  she  rallied  the  following  day,  and  though  the  subsequent 
course  of  the  case  was  precarious,  she  ultimately  made  a  complete  recovery. 
My  first  impression  of  the  case  was  that  it  was  one  of  pelvic  peritonitis  with 
cellulitis,  the  uterus  being  fixed,  and  n'ot  much  enlarged,  and  there  being  a 
defined  suprapubic  area  of  dulness.  The  advantage  of  the  abdominal  route 
was  well  shown  in  this  case.  An  excusable  error  might  have  been  made  of 
mistaking  the  case  for  a  pelvic  abscess  had  the  vagina  been  punctured. 

Impaction  of  Cyst. — The  cyst  may  be  impacted  and  fixed  by  adhesions  to 
the  uterus,  and  thus  appear  to  be  incorporated  with  the  latter,  making  the 
diagnosis  very  difficult — the  more  so  if  the  uterine  cavity  be  elongated  and 
should  menorrhagia  have  been  present.  Such  a  case  has  been  reported  by 
Tenison  ColHns,  in  Avhich  the  diagnosis  of  myoma  was  made ;  yet  the  tumour 
proved  to  be  a  tense  impacted  ovarian  cyst. 

Urachus  Cysts. — Lawson  Tait  first  described  cases  of  extra-peritoneal  cysts, 
closely  resembling  ovarian  cysts,  detailing  the  particulars  of  twelve  cases  in 
which  these  tumours  occurred.     The  cysts  appeared  in  two  instances  to  be 


OVAI{/A.\   CVSTOyfA—DIAoyOSIS   AND    TliEATMEST. 


759 


developed  from  the  urachus,  in  another  from  the  Fallopian  tube.  They  were 
not  intra-peritoneal.  In  fact,  in  some  instances,  there  appeared  to  be  an 
absence  of  the  pelvic  peritoneum.  The  cyst-walls  were  related  to  the  parietes 
in  front,  and  to  the  peritoneimi  posteriorly.  The  cysts  were  opened  and 
emptied  of  their  contents,  and  a  drainage-tube  inserted  ;  in  some  cases  the 
cysts  were  removed,  or  ]>ortions  of  the  cyst-wall. 

Physical  Signs,  Positive  and  Negative,  of  an  Ovarian  Tumour. 
Differential  Positive  Signs. 

A  tumour  at   lii*st  noticed  in  either  inguinal  region,   gradually 

becoming  central  ;  the  greatest   circumferential  measurement 

being  below  the  umbilicus ; 

lateral     measurement     in 

the  early  stages  increased 

from    the    middle    line   to 

the  vertebral    columns   or 

from  the  anterior  superior 

spine  to  the  umbilicus  of 

the  side  atiected. 
Outline  of  the  tumour  can  be 

defined. 
Abdominal  integument 

tense,  frequently  thinned — otherwise  not  abnormal. 
Later  stages  :  distension  of  abdominal  veins,  and  linese  albicantes 

seen. 
Fluctuation  limited  to  the  dull  area.     Wave  more  distinct  than, 

but  not  so  superficial  as,  the  ascitic  wave. 
Dulness  on  percussion,  central :   not  much  atfected  by  change  of 

posture ;  resonance  in  the  flanks  from  intestinal  displacement. 

It  must  be  remembered  that  the  presence  of  gas  in  the  cyst  cavity 

may  lead  the  practitioner  astray  by  the  resonant  note  it  gives 

to  percussion. 
Uterus  frequently  displaced  behind  the  cyst ;  on  vaginal  examina- 
tion the  uterus  is  frequently  found  drawn  up  from  the  examining 

finger  ;  the  cervix  may  be  shortened. 
Aortic  pulsations  (Atlee)  are  transmitted  through  the  tumour. 
The  '  facies  ovariana '  is  present  as  the  cyst  enlarges. 
The  fluid  drawn  by  aspiratioa  or  paracentesis  is  usually  of   an 

amber  colour,  but  varies  in  colour  and  consistence ;  it  is  viscid, 

of  specific  gravity  1015  to  1030  ;  contains  paralbumen  and  metal- 

bumeu  ;   when  examined  uader  the  microscope  various  forms  of 


Fig.  512. — Dull  Aeeas  ix  Ovakiax 
Tumour  axd  Ascites.    (Barnes.) 


760  DISEASES   OF   WOMEN. 

epithelial  cells  are  seen,  mixed  with  cholesterine  particles,  and  at 
times  oil-globules  or  blood-cells.  Atlee's  fibre  cell  is  present ;  the 
characteristic  cell  described  by  Drysdale  as  pathognomonic  is  a. 
non-nucleated  granular  cell,  on  which  ether  has  no  effect,  acetic 
acid  only  rendering  the  granules  more  distinct.  Exploratory 
incision  detects  the  bluish,  white,  or  glistening  and  smooth  wall 
of  the  cyst. 

Differential  Negative  Signs. 

The  general  health  does  not  rapidly  deteriorate. 

The  catamenia  are  not  generally    absent,    though  they  may  be 

scanty. 
There  is  seldom  menorrhagia. 

There  is  no  cardiac,  renal,  or  hepatic  disease  to  explain  the  dropsy. 
CEdema  of  the  extremities  is  not  present  (until  very  late  in  the 

disease). 
The  tumour  is  not  central  from  the  first ;  it  does  not  propor- 
tionately increase  from  month  to  month,  as  in  the  case  of  the 

pregnant  uterus ;  it  is  not  hard  and  resisting. 
The  umbilicus  is  not  prominent,  bulged  out,   watery-looking,  or 

thinned. 
The  integument  is  not  materially  altered  in  appearance  or  oedema- 

tous  ;  the  distension  of  the  superficial  veins,  as  a  rule,  comes  on 

late  in  the  disease. 
The  cachexia  of  malignant  disease,  and  of  organic  disease  in  the 

viscera,  or  of  malignant  ascites,  is  absent. 
The  most  important  signs  of  pregnancy  are  absent,  such  as  : 

Milk    in    the    breasts  (an   ovarian    tumour,    however,    may 

develop  during  prolonged  lactation)  ; 
The  foetal  pulsation  ; 
Uterine  contractions ; 

Ballottement  {a  solid  tumour  may  he  contained  in  an  enlarged 

cyst,  and  give  the  sense  of  ballottement  on  practising  this  test). 

The  possibility  of  pregnancy  being  complicated  by  the  presence 

of  ovarian  cystoma  has  to  be  remembered. 
The  OS  uteri  is  not  soft  and  patulous. 
The  uterine  cavity  is  not  (generally)  enlarged. 
The  uterus  does  not  move  with  the  tumour,  nor  is  the  uterus 

found    to    be    continuous    with   it    (recto-vaginal    and    utero- 

abdominal  methods). 


OVAIi/AN  CYSTOMA— 1> I AiSXOSfS  AND    TBEATMEXT.  KM 

There  is  no  history  of  rigors,  hectic,   great  pain,    and  nightly 

exacerbation  of  temperature  (unless  there  has  been  suppuration 

of  the  cyst  and  peritonitis). 
The  tumour  does  not  lessen  or  disappear  on  the  administration  of 

chloroform,  nor  can  any  considerable  depression  be  made  in  it 

under  the  influence  of  the  anaesthetic. 
It  does  not  diminish  perceptibly  when  the  bladder  is  emptied. 
There  is  no  inordinate  obesity  in  other  parts  of  the  body. 
The  fluid  is  not  of  \'ery  low  specific  gravity ;  it  is  not  pure  serum  ; 

it  does  not  spontaneously  coagulate ;  it  does  not,  when  kept, 

deposit  filamentous  particles  of  fibrine. 
Paracentesis  does  not  cure  the  disease. 
Exploratory  incision  does  not  expose  a  dark-coloured  and  vascular 

tumour. 

Diagnosis  of  Adhesions. 

Spencer  Wells,  in  writing  of  the  contra-indications  of  ovariotomy,  said  that 
adhesions  to  the  abdominal  wall  may  be  almost  disregarded.  Though  this 
may  be  so  in  the  bands  of  a  skilled  operator,  it  is  widely  different  with  those 
who  operate  for  the  first  time.  The  presence  of  adhesions  to  the  pelvic 
viscera  and  intestines  must  materially  influence  the  chances  of  a  successful 
operation. 

'  Adhesions  low  down  in  the  pelvis,'  says  the  same  author,  '  are,  on  the 
contrary,  of  gi-eat  importance.  The  difficult}^  is  to  separate  them  without 
serious  injury  to  the  rectum,  or  bladder,  or  the  irterus,  or  to  large  blood- 
vessels, or  to  nei-ves.  .  .  .  "When  deep-seated  and  very  intimate,  the  dissection 
necessary  is  out  of  the  question  in  the  living  patient,  and  gives  no  small  trouble 
in  the  dead.'  To  detect  adhesions  to  the  abdominal  wall,  the  patient  is  placed 
on  her  back,  with  the  knees  raised,  opposite  a  good  light,  and  the  abdomen 
must  be  entirely  uncovered.  The  proofs  that  Spencer  Wells  relied  on  that 
the  cyst  was  free  of  adhesions  to  the  abdominal  parietes  were  as  follows  :  (a) 
Movement  of  the  cyst-wall  visible  ivith  the  acts  of  respiration  (percussion 
enables  us  to  limit  the  superior  border  of  the  cyst,  and  prevents  pur  mistaking 
it  for  the  transverse  colon).  (&)  By  percussion  the  dull  sound  will  descend  in 
inspiration,  rising  again  in  expiration,  (c)  With  the  hands  placed  flatly  on 
the  abdominal  wall,  no  crepitus  can  be  felt,  which  maj^  be  present  if  any 
adhesive  cords  of  lymph  stretch  from  the  cyst  to  the  abdominal  wall :  audible 
crepitus  is  heard  when  the  lymph-surfaces  are  recent  (the  fact  that  omentum 
may  intervene  between  the  cyst  and  abdominal  wall  is  not  to  be  forgotten  ; 
with  free  omentum  lying  between  the  cyst-wall  and  the  parietes,  crepitus 
is  heard ;  not  so  if  adhesion  exists  between  the  cyst  and  parietes) ;  its  proximity 
to  intestine,  and  the  consequent  resonance  on  percussion,  and  the  softer  and 
doughy  feel,  help  to  distinguish  it.  (f/)  '  The  recumbent  patient  is  directed 
to  try  and  sit  up  without  assisting  herself  by  her  hands  or  elbows.  This 
effort  puts  the  recti  on  the  stretch,  and  if  a  tense  ovarian  cyst  be  free  from 


762  DISEASES   OF   WOMEN. 

adhesion,  it  falls  backwards  and  to  the  sides,  while  the  muscles  form  a  pro- 
jecting ridge  in  the  centre  of  the  abdomen.'  Only  when  the  adherent  cyst — 
it  may  also  occur  in  the  case  of  a  small  cyst — is  '  flaccid  or  partially  empty  ' 
is  this  appearance  seen,  (e)  The  umbilicus  moves  with  an  adherent  cyst. 
(/)  By  placing  the  woman  in  the  knee-elbow  position,  and  examining  the 
tumour  through  the  vagina,  if  there  be  pelvic  adhesions  it  does  not  yield  to 
digital  pressm-e,  and  the  uterus  may  be  pushed  out  of  position  or  fixed.  A 
portion  of  an  ovarian  cyst  may  occupy  the  pelvis  and  become  fixed  there, 
and  still  no  adhesions  exist,  {g)  If  there  have  been  recurrent  attacks  of 
peritonitis,  with  severe ,  pain  and  uterine  cramp,  we  may  suspect  that  there 
are  adhesions,  or  some  twisting  of  the  pedicle. 

From  these  signs  and  symptoms  we  are  enabled  to  say  :  (1)  that 
the  growth  is  ovarian ;  (2)  that  it  is  unilocular  or  multilocular ; 
(3)  that  it  is  not  malignant ;  (4)  that  it  is  not  a  cyst  of  the  paro- 
varium ;  (5)  that  there  are  or  are  not  adhesions  ;  (6)  that  inflam- 
matory changes  have  not  occurred ;  (7)  that  internal  haemorrhage 
is  not  going  on  into  the  cyst. 

It  is  seldom  that  the  careful  diagnostician,  proceeding  step  by  step  in  the 
examination  of  a  case,  will  fall  into  eiTor.  Keeping  clearly  in  his  mind  the 
possible  pitfalls  always  open  for  hasty  conclusions,  be  must  check  one  test  by 
the  application  of  another,  and  deliberately  balance  probabilities.  Should 
he  be  in  doubt  between  any  two  decisions,  he  will  carefully  apply  all  the 
facts  of  the  case  to  each  separately,  comparing  critically  the  weight  of 
evidence  which  inclines  him  one  way  or  other.  The  sxirgeon  has  to  re- 
member that  such  conditions  as  pregnancy,  encysted  dropsy,  ascites,  fibro- 
cystic disease  of  the  uterus,  extra-uterine  foetation,  hydramnios,  have  deceived 
the  most  experienced  living  authorities.  Therefore  he  will  hurriedly  express 
no  opinion  either  to  patient  or  friends ;  nor,  indeed,  will  he  commit  himself, 
in  case  of  doubt,  to  any  final  opinion,  without  a  full  examination  under  an 
anaesthetic,  in  an  obscure  case  of  '  abdominal '  or  '  pelvic  '  tumour,  until  such 
time  as  its  nature  is  clearly  deSned.  Should  any  uncertainty  remain,  it  is 
better  to  leave  the  question  an  open  one.  This  is  the  more  necessary,  as  in 
many  instances  he  may  not  have  the  means  or  opportunity"  of  applying  such 
crucial  tests  as  aspiration,  paracentesis,  the  microscope,  and  chemical  analysis. 
One  caution  more  I  may  add  here.  Even  when  the  fact  of  the  presence  of 
an  ovarian  cyst  is  decided,  we  have  to  recollect  that  complications  may  exist, 
such  as  pregnancy,  ascites,  inflammatory  conditions  of  the  pelvic  or  general 
peritoneum,  malignant  disease,  uterine  tumour,  cysts  of  the  abdominal  viscera, 
etc.  There  may  be  two  ovai'ian  tumours ;  one  may  escape  detection. 
(Should  the  two  ovaries  be  involved,  there  may  be  a  double  tumour  and  a 
well-marked  sulcus  between.)  Before  we  finally  express  any  decided  opinion, 
it  is  well  to  exclude  the  possibility  of  any  complication,  as,  through  it,  the 
case  afterwards  may  assume  much  more  serious  proportions,  and  there  may 
be  the  reflection  on  the  part  of  the  patient's  friends  that  it  had  escap.ed 
detection. 

Inflammation  and  suppuration  of  the  interior  of  the  tumour 


OVAIiLLX   CYSTOMA— I'lAQNOSIS  AND    TREATMENT.  7(;3 

may  be  suspected  if  there  be  rigors,  rapid  pulse,  diarrhoea,  hectic, 
and  elevation  of  temperature.  Such  inflammatory  action  may  lead 
to  rupture  of  the  cyst  and  discharge  of  its  contents  into  the  abdo- 
minal cavity,  or,  as  the  consequence  of  adhesions,  the  cyst  may 
empty  itself  through  a  fistulous  opening  by  the  abdominal  wall,  or 
discharge  itself  by  the  vagina,  bladder,  uterus,  or  rectum.  Death 
may  occur  ultimately  from  pyjemia  or  exhaustion. 

Internal  haBmorrhage  into  the  interior  of  the  cyst  will  be 
suspected  if  symptoms  of  severe  shock  occur  suddenly  with  collapse. 

Treatment. — This  practically  resulves  itself  into — 

General. 
Palliative. 
Removal  of  the  cyst. 

It  would  be  waste  of  time  to  discuss  the  general  treatment  of 
ovarian  tumours  by  drugs.  We  may  maintain  the  general  health 
and  support  the  patient's  strength  by  suitable  tonics  and  the 
administration  of  proper  nourishment,  while  we  see  that  sufficient 
time  is  spent  in  the  open  air,  and  the  mind  is,  as  far  as  possible, 
prevented  from  dwelling  on  the  malady  and  the  chances  of  recovery. 
The  bowels  require  attention,  and  the  bladder  may  have  to  be 
relieved  in  consequence  of  pressure ;  any  secondary  changes  in  the 
cyst,  or  such  an  accident  as  hfemorrhage,  must  be  dealt  with  as  they 
occur.  The  one  treatment  for  ovarian  tumour,  with  rare  exceptions,  is 
ovariotomy.  I  have  already  referred  to  the  operation  of  paracentesis 
abdominis  and  the  methods  of  performing  it,  and  vaginal  paracentesis. 

The  day  of  tapping  an  ovarian  cystoma  has  long  passed. 

[Spencer  Wells  did  not  consider  that  tapping  increased  to  any  appreciable 
extent  the  mortality  after  ovariotomy,  and  thought  that  in  cases  of  sirjople 
ovarian,  or  estra-ovariau,  cysts,  it  was  right  to  try  the  effect  of  one  tapping 
before  advising  a  patient  to  undergo  a  more  serious  risk. 

He  considered  that  tapping  might  sometimes  be  a  useful  prelude  to  ovario- 
tomy, either  as  a  means  of  gaining  time  for  a  patient's  general  health  to 
recover,  and  clearing  the  urine  of  its  load  of  albumen,  with  which  it  is  some- 
times charged  under  the  mere  influence  of  pressure,  or  of  lessening  shock  by 
relieving  her  of  the  fluid  a  few  hours  or  days  before  removing  the  solid  portion 
of  an  ovarian  cyst.] 

Tapping  through  the  rectum  is  a  step  which  need  not  be  con- 
sidered. This  and  all  other  palliative  measures  have  been  generally 
abandoned. 

Spencer  Wells'  obsei-vations  on  the  expediency  of  operating  are 
worthy  the  attention  of  all  surgeons  : — 


764 


DISEASES   OF   WOMEN. 


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OVAIilAN  CYSTOMA—DTAGNOSrS  AND    TEE  ATM  EST.         7t;5 

'I  have  become  more  and  more  disposed  to  advise  tlie  removal  of  an 
ovarian  tumour  as  soon  as  its  nature  and  coimections  can  bo  clearly  ascertained, 
and  it  is  begiiuiini!;  in  any  way,  physically  or  mentally,  to  do  harm,  since  the 
risk  of  the  operation  under  such  circumstances  is  certainly  less,  and  the 
possible  evils  of  delay  arc  eluded.  The  probable  result  of  ovariotomy  can  be 
estimated  with  far  greater  accuracy  by  a  knowledge  of  the  general  condition 
of  the  patient  than  by  the  size  and  condition  of  the  tumour.  In  other  words, 
a  large  tumour,  extensively  adherent,  in  a  patient  whose  heart,  lungs,  and 
digestive  and  eliminative  organs  are  healthy,  and  whose  mind  is  well  regulated, 
may  be  removed  with  a  far  greater  probability  of  success  than  a  small  un- 
attached cyst  from  a  patient  who  is  anismic  or  leukfemic,  whose  heart  is 
feeble,  whose  assimilation  and  elimination  are  imperfect,  or  whose  mind  is 
too  readily  acted  upon  by  either  exciting  or  depressing  causes.  I  believe  this 
to  be  the  explanation  of  the  facts  which  have  led  some  superficial  observers 
to  assert  that  the  more  advanced  the  disease  the  gi-eater,  and  the  earlier  the 
stage  of  the  disease  the  less,  is  the  probabihty  of  recovery.  I  am  convinced 
that  this  reasoning  is  based  on  the  observation  of  a  few  exceptional  cases 
where  small  unattached  tumours  have  been  removed  with  a  fatal  result  from 
unhealthy  or  infected  persons,  or  where  large  attached  tumours  have  been 
successfully  i-emoved  from  persons  who  have  otherwise  been  constitutionally 
soimd.  Small  unattached  tumours  in  strong  healthy  persons  have  by  no 
means  given  the  best  results.  It  is  possible  to  operate  too  early  as  well  as 
too  late — to  place  a  patient's  life  in  peril  hy  operation  before  it  is  endangered 
by  disease — just  as  it  is  possible,  on  the  other  hand,  to  delay  operation  until 
the  powers  of  life  are  so  exhausted  that  recovery  after  a  severe  operation  is 
impossible.' 

Ovarian  Tumours  complicating  Pregnancy.* 

The  dangers  from  ovarian  cystoma  complicating  pregnancy  arise 
from  its  growth,  the  torsion  of  the  pedicle,  suppuration  of  the  cyst 
contents,  the  solid  nature  of  the  tumour,  and  septic  infection  dui'ing 
childbed.  The  first  two  months  are  most  favourable  as  regards 
the  mother,  and  the  third  and  fourth  for  the  continuation  of  the 
pregnancy. 

Dsirne,  from  the  study  of  135  cases,  arrived  at  the  following  conclusions  : — 

1.  Tlie  further  pregnancy  progi"esses,  the  more  dangerous  is  the  situation 
for  mother  and  fojtus. 

2.  The  puncture  of  ovarian  cysts  and  the  production  of  abortion  are  to  be 
considered  only  in  emergency. 

3.  Ovariotomy  gives  the  best  results  for  the  mother  in  the  second,  third, 
and  fourth  months  of  pregnancy ;  for  the  product  of  conception  in  the  third 
and  fourth. 

4.  If  an  early  ovariotomy  be  not  possible  from  various  reasons,  it  is  to  be 
carried  out  in  the  later  months  of  pregnancy,  as  good  results  can  even  then 
be  expected. 

*  See  p.  748. 


766 


DISEASES   OF    WOMEN. 


From  statistics  of  Orgler  in  Landau's  kliuic,  the  mortality  from  ovariotomj' 
during  pregnancy  in  some  148  cases  did  not  exceed  2 '9  per  cent.,  while  in 
22*5  per  cent,  there  was  no  interruption  in  the  pregnancy.* 

Helier,  reporting  on  three  successful  cases  of  ovariotomy,  says, '  The  mortality 
of  the  expectant  method  was  found  by  Remy  to  be  2.3  per  cent,  for  the 
mother  and  39  per  cent,  for  the  child.'  f 

Thus  we  see  that,  save  in  the  case  of  parovarian  cysts,  which  may 
be  emptied  through  the  vagina  by  tapping,  the  coui'se  to  pursue  is 
to  remove  the  ovarian  tumour  at  the  earliest  possible  date  of  the 
pregnancy.  Still,  if  the  tumour  be  not  discovered  until  very  late 
in  the  gestation,  or  that  labour  is  approaching,  it  should  be  dealt 
with  by  paracentesis. 


Fig.  512a. — Catch  with  Weight  for  Holding  the  PEPaTONEAL  Edges  open. 

(Author.) 

Natural  size.  The  whole  can  be  sterilized.  The  weight  is  made  of  lead.  The 
grip  on  the  peritoneum  is  quite  sufficient,  and  does  not  tear.  It  takes  the 
place  of  forceps,  and  is  out  of  the  way,  the  weight  hanging  over  the  side  and 
everting  the  edges  of  the  peritoneum.  A  tie-clip  will  answer  the  same 
purpose. 


*  Arcliiv.  f.  Gyn.,  vol.  Ixv.,  No.  1. 
T  Lancet,  Bee.  21,  1901. 


CHAPTER    XL. 

CLASSIFICATION    AND    PATHOLOGY    OP    SOLID 
TUMOURS    OF    THE    OVARY. 

The  solid  tumours  that  are  found  in  connection  with  the  ovary  and 
the  structures  connected  with  it  may  be  chxssified  as  follows  : — 

L  Fibromata. 

2.  Myomata. 

3.  Sarcomata. 

4.  Carcinoma. 

5.  Endothelioma. 

6.  Gyroma. 

7.  Tubercle. 

For  the  better  understanding  of  this  classification  the  student 
should  study  in  connection  with  it  Fig.  486,  which  shows  diagram- 
matically  the  various  structures  involved.  He  should  also  bear  in 
mind  that  an  organ  is  liable  to  any  kind  of  new  growth,  of  which 
the  physiological  prototype  is  found  in  its  individual  tissues.  We 
find  accordingly  that  from  the  connective  tissue  elements  in  the 
ovary  are  derived  Fibroma  and  Sarcoma ;  from  the  muscular  tissue 
prolonged  into  the  ovary  from  the  ovarian  ligament,  Myoma ;  from 
the  epithelial  elements  in  the  ovarian  follicles,  Carcinoma ;  from  the 
follicles  themselves,  cysts — Adenoma,  or  Dermoid  ;  fi*om  the  paro- 
ophoron are  derived  papilloma ;  from  the  persistent  mesonephric 
tubules.  Parovarian  cysts ;  and  lastly,  from  a  persistent  meso- 
nephric or  Wolffian  duct  may  arise  a  Gartnerian  cyst  (Bland- 
Sutton). 

In  describing  the  tumours  of  tbe  ovary,  the  order  adopted  in  the 
above  classification  will  be  followed. 

A.  Tumours. — 1.  Fibromata. — These  rare  tumours  of  the  ovary 
attain  dimensions  varying  from  that  of  a  hen's  egg  to  about  three 
times  this  size.  According  to  many  authors  they  occur  most  fre- 
quently in  young  women.    Peterson  has  collected  a  list  of  eighty-two 


768 


DISEASES   OF    WOMEN. 


cases  of  fibroma  of  the  ovary,  all  of  which  had  been  submitted  to 
the  test  of  microscopical  examination.* 

Of  seventeen  cases  recorded  by  Leopold,  thirteen  were  in  patients  from 
5  to  30  years  of  age,  and  only  four  in  women  above  30.  Dartigues,  on  the 
other  hand,  found  that  of  twenty  cases,  six  occurred  from  20  to  30,  six  from 
30  to  40,  six  from  40  to  50,  and  two  above  the  age  of  50.  Large  tumours 
have  been  recorded,  weighing  from  1 0  to  20  lbs. ;  but  these  have  been  fibro- 
myomata,  not  pure  fibromata. 

In  relation  to  the  developments  of  fibroma,  the  connective  tissue 
of  the  embryonic  type  which  exists  round  the  follicles  of  the  ovary 
(Doran),  and  its  presence  in  the  ovarian  ligament  must  be  re- 
membered. The  growth  almost  always  affects  one  ovary  only. 
The  Fallopian  tube  is  separate  and  free,  except  in  the  case  of  some 


Fig.  513. — Fibeoma  of  both  Ovaries.    (Cullingwoeth.) 

of  the  larger  tumours ;  the  pedicle  is  formed  by  the  broad  ligament, 
and  is  usually  rather  slender.  The  tumour  appears  as  a  smooth, 
rounded,  or  lobulated  mass,  greyish-white,  or  of  a  marbled  aspect ; 
it  feels  firm,  and  on  section  presents  a  surface  usually  solid,  but 
sometimes  dotted  over  with  a  small  cystic  degeneration.  There  is 
no  definite  capsule  such  as  is  found  in  the  case  of  uterine  fibromata. 
These  growths  present  a  marked  contrast  to  the  malignant  ovarian 
turuours,  in  the  absence  of  ascites  and,  usually,  of  adhesions ;  when 
the  latter  are  present,  they  are  mostly  omental.  Fibromata  are 
apt  to  undergo  calcification  and  even  ossification,  more  rarely 
suppuration. 

*  Peterson  did  not  include  in  this  number  the  author's  case,  p.  752. 


SOLID    TUMOUBS  OF  THE  OVARY.  769 


Some  cases  described  as  fibromata  have  really  been  sarcomata ; 
others  have  properly  belonged  to  one  or  other  of  the  varieties  of 
mixed  growths,  such  as  libro-myoma,  libro-surcoma ;  lastly,  some 
should  be  classed  as  myomata  or  cavernous  fibromata.  Pure  fibro- 
mata have,  however,  been  met  with,  though  they  are  undoubtedly 
very  rare.  Rokitansky  has  described  a  special  variety  under  the 
name  of  fibroma  of  the  corpus  lutem. 

Cullingworth  exhibited  before  the  Obstetrical  Society  of  London  an  in- 
teresting specimen  of  fibroma  of  both  ovaries,  which  he  removed  after  death 
from  a  woman,  aged  thirty-six,  who  died  of  ascites  (Fig.  513).  She  had  been 
pregnant  five  years  previously,  and  had  noticed  a  swelling  in  the  right  groin 
about  this  time  at  the  conclusion  of  the  pregnancy.  The  tumours  lay  in 
front  of  and  behind  the  uterus — the  larger  of  the  two  behind.  They  were 
non-adherent,  and  in  parts  of  a  cystic  character.* 

The  following  is  an  instructive  case,  as  it  not  alone  exemplifies 
the  difficulties  of  diagnosis,  but  also  is  a  typical  example  of  pure 
fibroma  of  the  ovary. 

Case  of  Fibroma  of  the  Ovary. — The  patient,  unmarried,  and  twenty-two,  con- 
sulted me  for  persistent  sickness  associated  with  periodical  epigastric  pain  and 
considerable  anaemia. 
For     eighteen     months 
previous  to    seeing    me 
the  catamenia  had  been  '  - 

absent.  These  were  the 
only  symptoms.  A 
careful    examination    of         , 

the     lungs,     heart,    ab-      /  ' 

dominal,  and  pelvic  vis-     '  .     ■  1 

cera    gave    a    negative    f;  i 

result.    A  Weir-Mitchell    |V'  -j 

course  and  an  examina-     i  / 

tion   of  the    urine   and      \.  '■'  I 

blood    were     suggested,       0 
fearing  that  the  ansemia  - 

might  be  of  a  pernicious 
character.       A    vaginal  "^ .!; 

examination   was    made  \_ 

the  next  day  under  anses-  ^^^^..^-^ 

thesia,  and  a  tumour  was        ^^^^   514.— MicRO^outil^L  .Section  (J-in.   obj.)  of 
discovered  lying  between      Fibromatous  Tumour  of  the  Ovary.    (Author.) 
the  uteinis  and  bladder 
in  the  middle  fine,  hard  and  movable.     The  patient  herselt  was  unaware  of 

*  Obittt.  Soc,  vol.  i.,  1879. 

3    D 


770  DISEASES  OF  WOMEN. 

its  existence,  nor  had  she  suffered  any  pain  other  than  the  epigastric.     The 
choice  lay  between  a  dermoid  cyst  or  a  fibroma  of  the  ovary.     Its  freedom 

from  both  bladder  and 
utenis  was  ascertained, 
though  it  was  evident  that 
by  the  distended  bladder 
on  the  previous  morning 
it  had  been  raised  from 
its  pelvic  position,  to 
which  it  sunk  when  the 
bladder  was  empty. 

The  tumour  was  easily 
removed,  and  the  patho- 
logical report  was  as 
follows : — 

'  The  ovarian  tumour 
shows  microscopically 
nucleated  spindle  -  celled 
tissue,  which  is  arranged 
in  very  definite  interlacing 
bundles.  The  coarseness 
Fig.  515.— Mickoscopical  Section  (1-in.  obj.)  of  of  the  tissue,  the  distinct 
FiBEOMATOus  TuMoxTR  OF  THE  OvAET.     (AuTHOR.)     formatiou   of  fibrcs,    and 

their  wavy  arrangement, 
are  good  reasons  for  regarding  the  tumour  as  a  fibroma  rather  than  a  sarcoma. 
Sections  have  been  made  from  different  parts,  and  they  all  show  the  same 
appearances.  The  vessels  in  the  tumour  are  numerous  and  well  formed.' 
(Figs.  514,  515.) 

'  The  naked-eye  appearance  of  the  small  fragments  of  the  ovarian  tumour 
which  have  been  preserved  is  somewhat  like  that  of  uterine  fibroid.  The  cut 
surface  shows  white  fibrous  strands  which  interlace,  but  are  not  arranged  in 
whorls.  Here  and  there  small  gi'ey  areas  may  be  seen  distributed  among  the 
Avhite  strands.  There  is  a  distinct  capsule  composed  of  thick  white  peritoneum 
and  a  subjacent  layer  of  cellular  tissue  traversed  by  numerous  vessels,  some 
of  ,which  are  of  considerable  size.  Se-pta  pass  from  this  capsule  into  the 
tumour  for  a  short  distance,  indicating  that  the  tumour  has  a  tabulated  out- 
line. The  serous  surface  of  the  fragments  is  quite  free  from  adhesions. 
The  tumour  as  a  whole  feels  firm  and  elastic,  but  less  dense  than  the  common 
fibroid.' 

The  other  ovary  was  not  typically  healthy,  as  there  was  some  cystic 
proliferation,  and  it  was  very  slightly  enlarged.  However,  there  was  nothing 
to  demand  its  removal. 

The  points  of  interest  in  the  case  are,  the  youth  of  the  patient, 
the  absence  of  menstruation,  the  painlessness  of  the  tumour,  its 
extreme  hardness  to  the  touch,  its  freedom  and  mobility,  and 
associated  movement  with  the  bladder. 


SOLID    TUMOURS  OF  THE   0VAR7. 


Ill 


2.  Myoma  of  the  Ovary. — Muscular  tissue  is  found  both  in  the 
parenchyma  of  the  ovary  in  its  vascular  coats,  and  in  free  bundles 


F.T.. 


r 


'l^ 


Oc.  fim,. 


Cu. 


-I  #        / 


Ov.  lig. 


My. 


Fig.  516. — Myoma  op  the  Ovary.     (Dokan.) 

Xat.  size.  F.T.,  Fallopian  tube.  3Ies.,  Mesosalpinx,  not  involved  in  the 
growth.  Cy.,  ovarian  cyst,  2^  inches  in  length.  Ov.  Jim.,  ovarian  fimbria 
of  the  tube  passing  on  to  the  cyst.  Oo.  lig.,  ovarian  ligament,  divided  at 
operation  close  to  uterus.  It  runs  directly  into  the  junction  of  the  cyst  to 
the  vagina.  My.,  solid  myoma,  showing  the  groups  of  myomatous  nodules 
(as  often  seen  in  interstitial  uterine  fibroids)  of  which  it  was  made  up. 
Ko  perimetritis  nor  salpingitis. 


derived  from  the  ovarian  ligament,  which  is  really  a  process  of 
the  uterus,  running  through  the  ovary  (Doran).  The  occurrence 
of  myoma  of  the  ovary  is  thus  accounted  for.     It  is,  however,  a 


772 


DISEASES   OF   WOMEN. 


rare  form  of  tumour,  and  clinically  is  indistinguishable  from  fibroma. 
Large  myomata  have  been  recorded  as  springing  from  the  ovarian 
ligament. 

Pure  myoma  of  the  ovary  has  been  recorded  by  Singalli.  The 
muscular  fibres  were  of  the  non-striated  variety  ;  Vignai'd  described 
a  case  in  which  they  were  striated,  but  this  was  in  a  myo-sarcoma. 
Gessner  also  has  recorded  a  case  of  true  myoma. 

Baldy  '■•"  reported  a  case  of  pure  myoma  of  the  ovary.  It  hung  free 
in  the  peritoneal  cavity,  having  a  sub-peritoneal  connective  tissue 
attachment  to  the  fibroid  uterus,  and  all  the  anatomical  relations 
to  the  tube  and  ovarian  ligament  of  the  ovary.  It  contained  ovarian 
tissue  ;  the  fimbriated  end  of  the  tube  disappeared  in  the  capsule  of 
the  tumour  at  its  distal  end.  He  considered  from  its  anatomical 
surroundings  that  it  developed  in  the  ovarian  ligament,  and  not  near 
the  capsule  of  the  ovary .f 

3.  Sarcoma. — This  is  the  most  common  of  the  solid  tumours  of 
the  ovary.    It  has  been  traced  to  the  theca  of  the  Graafian  follicles. 

The  round  cells  of  the  sar- 
coma bear  a  close  resem- 
blance to  the  cells  lining  the 
follicles.  They  have  been 
seen  at  all  ages,  from  10  to 
60,  Some  authors  maintain 
that  sarcomata  are  most 
prevalent  in  childhood ;  and 
it  can  at  least  be  said  that 
of  the  solid  ovarian  tumours 
found  in  children,  sarcomata 
are  by  far  the  most  fre- 
quent, but  Dartigues  found 
that  of  twenty  cases,  only 
two  occurred  in  patients 
under  20,  five  between  20 
and  30,  four  between  30 
and  40,  seven  between  40 
and  50,  and  one  at  60.  It  has  been  observed  in  the  case  of 
fibromata  that  the  majority  of  the  patients  had  been  sterile ;  it  is 
otherwise  with  sarcoma,  which  has  been  found  most  often  afiecting 

*  Amer.  Gyn.,  Nov.,  1902. 

t  Doran  has  detailed  the  particulars  of  a  case  of  undoubted  myoma  of  the 
ovary  and  ovarian  ligament,  in  the  Edinburgh  Medical  Journal,  1898. 


Fig.  517. — Sai;cujia  of  the  Ovary. 
(Dor.Ax.) 

From  a  portion  where  much  fibrous  tissue 
was  blended  with  spindle  cells. 


o 


P4 


SOLID   TUMOURS   OF  THE   OVARY.  773 

multiparae.  Sarcomata  are  among  the  largest  of  the  solid  tumours 
aliecting  the  ovary  ;  the  majority  attain  the  size  of  a  list,  a  fcetal 
head,  and  even  an  adult  head,  and  remarkable  instances  of  even 
greater  size  are  on  record,  as,  for  instance,  Homan's  case  of 
22  lbs.,  Yiguier's  of  44  lbs.,  and  Clemens'  of  88  lbs.  These 
tumours  are  often  bilateral ;  they  present  a  whitish  aspect,  with  the 
surface  often  marked  with  a  fine  vascular  network.  It  is  not  un- 
usual to  find,  on  section,  numerous  cavities  resulting  from  cystic 
degeneration.  The  pedicle  is  often  thick  and  fleshy,  notwithstand- 
ing which  it  is  very  prone  to  torsion.  This  complication  is  favoured 
by  the  abundant  ascites  which  is  usually  present,  and  in  consequence 
of  which  the  tumovir  has  considerable  mobility.  In  other  cases 
the  tumour  becomes  fixed  by  adhesions,  principally  to  intestine  and 
omentum,  and  less  often  to  the  uterus  and  the  adjacent  pelvic 
peritoneum.  Secondary  deposits  are  common  in  distant  organs, 
such  as  the  liver,  lungs,  breast,  and  bones ;  whilst  a  difiuse  metas- 
tasis may  occur  over  the  peritoneum.  Several  histological  varieties 
have  been  described,  of  which  the  most  malignant  appears  to  be  the 
small  spindle-celled  type.  The  mixed  forms,  such  as  fibro-sarcoma, 
sarco-myoma,  and  sarco-lipomata,  are  less  malignant.  Myo-sarcoma, 
with  non-striated  muscular  fibres,  has  been  described  by  Virchow, 
and,  as  we  have  seen,  Vignard  has  recorded  a  case  where  the  muscle- 
fibres  were  striated.  Endothelioma  has  also  been  included  among 
the  sarcomata. 

Stauder  reported  from  the  University  Frauenklinik  at  Wuerzburg  that  out 
of  295  ovariotomies  there  were  20  cases  of  sarcoma  aud  endothelioma  of  the 
ovary.  The  ronnd-ceUed  sarcomata  show  the  greatest  tendency  to  metastases. 
Final  cure,  according  to  Pfannenstiel,  is  obtained  in  some  50  per  cent.* 

4.  Carcinoma. — Cancer  of  the  ovary,  secondary  to  the  disease  in 
the  uterus  or  breast,  is  not  uncommon ;  but  primary  ovarian  cancer 
is  rare,  though  apparently  not  so  rare  as  fibroma. f  It  is  specially 
prone  to  attack  women  at  or  after  the  time  of  the  menopause,  but 
cases  have  also  been  recorded  in  quite  young  women,  and  six  in 
children.  The  growth  seldom  attains  such  large  dimensions  as  are 
found  in  the  case  of  sarcomata.  As  a  rule,  both  sides  are  affected. 
In  the  majority  of  recorded  cases  the  patients  were  miiltiparse.  In 
appearance,  these  tumours  are  usually  of  irregular,  nodular  form  ; 
dark  in  colour,  ranging  from  wine-red  to  purple.     The  consistence 

*  Zeitsch.  /.  Geh.  Gyn.,  bd.  47,  ht.  c. 

t  Cancer  of  the  Ovaries.— Kougnetsky  (Amer.  Gyn.,  Mar.  1904)  has  recorded 
the  particiilars  of  a  case  of  primary  cancer  of  both  ovaries  in  a  girl  aged  14. 


774 


DISEASES   OF   WOMEN. 


4  " 


-1^/:^ 


-y 


-/ 


Fig.  518. — Peimary  Caecinoma  of  the 
OvAEY — Soft.    (ArTHOE.) 


varies  with  the  -  histological  characters  :  the  encephaloid  variety  is 
soft  and  elastic,  but  the  scirrhus,  as  in  other  parts  of  the  hody,  is 

hard    and    even    stony, 


and  on  section,  as  French 
authors  express  it,  '  crie 
sous  le  scalpel.^  Ascites 
is  a  constant  feature  of 
ovarian  cancer ;  the  fluid 
is  less  abundant  than  is 
the  case  with  sarcoma, 
but  is  usually  blood- 
stained. Hydrothorax 
is  frequently  also  pre- 
sent, even  apart  from 
secondary  deposits  in 
the  pleura.  These  re- 
marks apply,  not  only  to 
primary  ovarian  cancer, 
but  also  to  the  secondary 
form,  and  to  cysts  undergoing  malignant  changes.  Metastasis 
occurs  in  the  lymphatic  glands,  and  in  distant  organs,  such  as  the 

lungs,  liver,  and  intes- 
tines ;  and  by  direct 
extension  the  growth 
may  involve  the  uterus 
and  adjacent  pelvic  peri- 
toneum. The  ovary  is 
specially  liable  to  can- 
cerous metastases  from 
primary  cancer  in  the 
other  abdominal  organs. 
This  may  be  due,  as 
Kraus  "  believes,  to  im- 
plantation of  the  can- 
cerous particles  on  the 
ovarian  epithelium,  pro- 
liferating in  the  ovarian 
substance,  or  in  the  con- 
nective tissue  of  the  stroma,  travelling  along  the  course  of  the 
bloodvessels  and  lymphatics,  and,  as  we  have  elsewhere  shown, 
*  Monat.f.  Geh.  und  G-yn.,  bd.  14,  ht.  1. 


'^5 


Fm.  519.- 


-Peimaey  Caecixoma  OF  Oyaey- 

SCIRRHUS.      (TaEGETT.) 


PLATE   CXV. 


^ 

^     mfl 

^^^^^^A 

^^Ka 

^*^''^— ■■ 

o  .2 


PLATE    CXYI. 


"   a 
^-  5 


y.     ,_ 

—       3 


SOLID    TUMOUnS   OF   THE    OVARY.  llh 

implantation  metastases  from  ovarian  adeno-cystomata  and  carci- 
nomata  occur  in  the  abdominal  wall.  Microscopically,  two  forms 
can  be  distinguished — scirrhus  and  glandular  carcinoma.  The 
examination  requires  to  be  made  with  great  care,  for,  as  Bland- 
Sutton  points  out,  the  alveolar  disposition  of  cancer  is  imitated  ])y 
ovarian  follicles  being  entangled  among  the  cells  of  the  tumour  in 
some  cases  of  sarcoma. 

Carcinoma  of  one  Ovary  and  Andeno- Fibroma  of  the  other. — The  tumours 
shown  in  Plates  CXV.,  CXVI.  were  removed  from  a  widow,  whose  last 
catamcnial  period  occurred  one  year  'previous  to  my  seeing  her,  and  the 
last  marital  act  nine  months.  It  had  been  taken  for  granted  that  she  was 
pregnant,  and  the  only  symptoms  from  which  she  suffered  were  attacks  of 
diarrhosa  and  sickness,  which  had  lasted  for  six  months.  Before  operation 
she  was  greatly  emaciated  and  very  weak.  The  abdomen  presented  the 
shape  and  character  generally  seen  with  ovarian  cystoma.  The  abdomen 
was  the  size  of  the  eighth  month  of  pregnancy.  The  skin  was  tightly 
stretched  over  a  large  solid  mass,  in  parts  of  stony  hardness;  this  was 
movable,  and  appeared  lobulated,  while  a  sulcus  to  the  left  side  seemed  to 
divide  it  from  a  second  mass  occupying  the  left  inguinal  region.  The  uterus 
could  be  disassociated  from  the  tumour  or  tumours,  the  cervix  was  very  hard, 
and  the  uterus  moved  with  the  mass.  The  diagnosis  was  malignant  ovarian 
tumour.  On  opening  the  abdomen  by  an  incision  which  had  to  extend  from 
the  ensiform  cartilage  to  the  pubes,  in  order  to  deliver  the  large  tumour, 
some  ascitic  fluid  escaped.  The  tumour  was  easily  delivered,  and  the  pedicle 
secured. 

The  second  (left)  tumour  was  then  removed,  and  the  pedicle  dealt  with 
(Plate  CXVI.).  The  only  complication  (a  serious  one  for  some  time)  was 
a  return  of  diari'hcea,  which  caused  considerable  ti'ouble,  and  made  the 
administration  of  nourishment  also  difficult.  However,  the  patient  left  for 
the  seaside  one  month  after  operation,  greatly  improved  in  health.  How 
emaciated  she  was  before  the  operation  may  be  judged  from  the  fact  that 
she  only  weighed  6  st.  5  lbs.  before  going  out  from  the  Home.  The  patient 
lived  for  over  five  months  after  operation,  ultimately  dying  of  carcinoma  of 
the  omentum.     Mr.  Target  examined  the  tumours. 

Pathological  Report :  '  The  large  solid  tumour  of  the  ovary  was  a  scirrhus 
carcinoma.  The  smaller  specimen  was  a  solid,  pyi'iform  tumour,  measuring 
four  inches  by  two  and  a  half  inches.  It  had  a  somewhat  nodulated  exterior. 
The  cut  surface  showed  a  rounded  gelatinous  area  in  the  broader  end  of  the 
tumour.  'J'his  area  measured  two  and  a  half  inches  in  diameter,  and  was 
fairly  well  defined.  The  rest  of  the  tumour  was  fibrous  and  traversed  by  large 
thin- walled  vessels.  The  gelatinous  area  is  not  quite  homogeneous  in  appear- 
ance, the  peripheral  zone  being  more  gelatinous  than  the  rest.  The 
Fallopian  tube  and  mesosalpinx  were  normal.' 

Krugenberg's  Tumour  of  the  Ovary. — In  this  affection  nodular 
deposits  of  a  malignant  nature  are  found  in  the  ovary.     They  may 


776 


DISEASES  OF   WOMEN. 


be  hard  and  fibrous,  or  of  a  softer  consistence.  In  them  are  charac- 
teristic seal-ring  and  epithelial  cells.  Wagner  looks  upon  these 
tumours  as  metastases  of  gastric  scirrhus.  There  is  a  mucoid 
metamorphosis  of  the  epithelial  cells  of  ovarian  scirrhus. 

The  following  table,  showing  the  characteristics  of  the  principal 
solid  tumours  of  the  ovary,  is  based  on  a  valuable  synopsis  of  solid 
tumours  of  the  ovary  by  Dartigues.* 


Occurrence .. . 

OVARIAN   FIBROMTOMA. 

OVAKIAN   CAKCINOMA. 

OVAEIAN   SARCOMA. 

Bare. 

Rarer  than   sarcoma, 

The  least  rare  of  the 

less   rare   than  fib- 

solid tumours. 

roma. 

^iffe 

20   to   60 ;    some  au- 

Middle life,  40  to  50 ; 

Mostly  over  50 ;  occa- 

thors say  mostly  in 

some  say  mostly  in 

sionally  before  25. 

young  women. 

childhood. 

Minor  bilate- 

Usually     only      one 

Both       sides       often 

Both    sides    usually 

ral 

ovary  affected. 

affected. 

affected. 

Colour 

Whitish       grey       or 

Whitish,    with    light 

Reddish  or  purple. 

marbled. 

vascular  network. 

Character   ... 

Usually           smooth, 

Usually      shape      of 

Mostly  nodular   and 

rounded     reniform 

much          enlarged 

lobulated. 

or  lobed. 

ovary. 

Size 

Seldom  larger  than  a 

Often  size  of  foetal  or 

Size  from  fist  to  fcetal 

fist;    often   size  of 

adult  head. 

head. 

egg- 

Adhesions    ... 

Intestinal     adhesions 

Often    adhesions     to 

Usually     no      adhe- 

rare;       sometimes 

intestine  and  omen- 

sions, tumour  mo- 

omental;        uterus 

tum,  with  fixation 

bile  though  large. 

usually  free. 

of  uterus,  etc. 

Consistence... 

Firm  consistence ;  no 

Elastic,       sometimes 

Hard, sometimes  elas- 

capsule;    solid    on 

soft,    often    cj'stic 

tic,    cuts    harshly, 

section,      or     with 

transformation ; 

cancer     juice     on 

small  cysts. 

sometimes      caver- 
nous,    from     large 
vessels. 

scraping. 

Histological 

Pure  fibroma. 

Scirrhus. 

Pure  sarcomata. 

varieties 

Fibromyoma. 

Encephaloid. 

Fibro-sarcoma. 

Pure  myoma. 

Myxo-sarcoma. 

Fibroma     of     corpus 

Lipo-sarcoma. 

luteum. 

Cavernous  fibroma. 

Endothelioma. 

Ascites 

No  ascites. 

Abundant          ascitic 

Blood  -  stained       as- 

fluid,   greenish    or 

citic  fluid,  usually 

straw-coloured. 

scanty. 

Metastases  ... 

No     metastatic     de- 

Deposits     in      liver. 

Deposits  in  lymphatic 

posits. 

lungs,         stomach, 

glands,   pelvic   or- 

breast,   bones,    and 

gans,    and   distant 

peritoneum. 

viscera. 

5.  Endothelioma. — Forty-one  cases  of  endothelioma  of  the  ovary 
were  recorded  up  to  1903.f 

Mary  Dixon  Jones  was  among  the  first  who  investigated  and 
described  the  pathological  features  of  both  endothelioma  and  gyroma. 

.  *  Bevue  Gyn^cologie  (Pozzi),  June- August,  1899. 
t  Lange,  Central./.  Gyn.,  1903,  No.  3. 


SOLID    TUMOURS  OF  THE   OVARY.  777 

Endothelioma  is  a  new  formation  of  blood  corpuscles  and  blood- 
vessels, originating  in  pre-existing  bloodvessels,  from  the  endothe- 
lium of  which  the  new  growth  is  derived.  It  invades  a  great  part 
of  the  ovarian  tissue,  and  is  generally  associated  with  diseased  ova, 
many  of  which  show  indications  of  colloid  degeneration,  with  the 
formation  of  cysts,  the  walls  of  which  are  formed  by  a  stratified 
layer  of  inflammatory  tissue.  It  frequently  gives  rise  to  hremato- 
mata  and  blood  cysts  in  the  ovary.  These  blood  cysts  seriously 
imperil  the  life  of  the  patient. 

6.  Gyroma  appears  in  the  form  of  a  number  of  small  nodular 
fibromata  occupying  the  substance  of  the  ovary ;  like  endothelioma, 


Fig.  5:^11. — Exdothelioma  of  the  Ovaet.    (Ludwig  Pick.) 

it  is  regarded  as  the  result  of  inflammation,  of  septic  origin.  It 
starts  as  an  inflammation  of  the  Gx'aafian  follicles.  Xormally,  a 
delicate  membrane  of  a  highly  refractive  character  is  all  that  should 
remain  of  such  a  follicle  ;  but  when  it  is  inflamed  the  membrane 
becomes  thicker  and  convoluted,  and  is  crowded  with  inflammatory 
corpuscles,  till  at  last  there  is  formed  a  broad,  firm,  convoluted 
wall ;  or  there  is  developed  what  the  writer  at  first  called  '  nodular 
fibromata,'  and,  later  on,  '  abnormal  menstrual  bodies.'  Corpora 
lutea,  as  originally  described,  are  regarded  by  Mary  Dixon  Jones 
as  belonging  to  the  category  of  gyromata. 


778  DISEASES   OF   WOMEN. 

The  two  forms  of  growth — Endothelioma  and  Gyroma — are  fre- 
quently found  associated,  and  they  give  rise  to  similar  symptoms, 
viz.  pain,  often  agonizing,  a  progressive  emaciation,  and  a  cachectic 
condition  of  the  whole  system.  In  some  cases  the  loss  of  weight 
may  amount  to  20,  30,  or  40  lbs.  The  patient  becomes  a  chronic 
invalid,  unable  to  follow  any  employment,  and  subject  to  various 
nervous  disturbances,  amounting  in  some  cases  to  melancholia  or 
dementia.  The  only  treatment  of  any  avail  is  the  removal  of  the 
affected  ovaries. 

A  case  was  reported  by  Cullen  of  endothelioma  of  the  ovary,  which  was 
attached  to  the  rectum  and  sigmoid  flexure,  involving  the  uterus  and  the  sac 
of  Douglas.  It  was  a  round  and  spindle-celled  angio-sarcoma,  with  some  of 
the  characteristics  of  endothelioma.  The  cells  were  arranged  round  the 
bloodvessels.  *  The  vessels  had  an  inner  lining  of  endothelium,  surrounding 
which  in  some  places  is  a  delicate  muscular  coat,  the  outer  portions  of  which 
appear  to  have  undergone  hyaline  degeneration.  Immediately  surrounding 
the  muscular  coat  were  eight  to  ten  layers  of  spindle-shaped  cells  running 
parallel  to  the  vessel.' 

'  These  tumours  have  two  chief  sources  of  origin  :  first,  those  arising  from 
the  bloodvessels  (Amann — four  cases,  Ackermann,  Eckardt^  Marchand) ; 
second,  those  springing  from  the  lymphatics  (Amann,  Flaischlen,  Leopold, 
Marchand,  Pomorski,  v.  Rosthorn,  v.  Velits  and  Voight).  These  two  divisions 
are  again  subdivided  according  as  the  sarcoma  arises  from  the  outer  sheath 
of  the  vessels  or  from  their  endothelial  lining. 

'  The  case  quoted  was  undoubtedly  perithelial  in  origin,  growing  from  the 
outer  coats  of  the  bloodvessels.  As  it  is  sometimes  very  difficult,  and  in  fact 
impossible,  to  say  whether  it  arises  from  the  outer  or  inner  sheath  of  the 
vessels,'  Cullen  thinks,  'the  two  divisions  are  sufficient,  viz.  those  arising 
from  the  bloodvessels  and  those  springing  from  the  lymphatics. 

'  The  tumours  have  occurred  in  children  7  years  of  age,  and  in  women  64 
years  old.     The  average  of  eleven  cases  was  33  years.' 


PLATE    CXVII. 

D 


Hydated  Cyst  *  connected  with  Eight  Ovary.    (C.  J.  Cullingwokth.) 

A,  hydatids  of,  or  attached  to,  right  ovary,  seen  through  the  transparent  cyst- 
wall.  B,  the  same  exposed  to  view  by  cutting  out  a  window  in  the  cyst- 
wall.  C,  torn  remains  of  hydatid  cyst  of  the  right  broad  ligament.  D, 
right  Fallopian  tube. 

In  this  case  hydatid  cysts  were  also  connected  with  both  ovaries  and  the  right 
broad  ligament.  The  liver,  omentum,  and  mesentery  were  also  invaded. 
The  pelvic  cysts  were  first  successfully  removed  by  CuUingworth,  and 
there  were  eight  subsequent  operations,  two  performed  by  CuUiugworth 
and  sis  by  H.  H.  Clutton,  for  the  removal  of  hydatid  cysts  from  various 
situations  (]896-1903).t 

*  See  pp.  082,  860,  951  for  hydatids  of  the  Fallopian  tube  and  uterus, 
t  Join:  Ob^t.  and  Gyn.  Brit.  Emp.,  July,  1904. 

[To  face  p.  778. 


CHAPTER   XLI. 

AFFECTIONS    OF   THE    OVARIES  (continued). 

The  Operations  of  Salpingo-odphorectomy  and  Ovariotomy  for 
Ovarian  Cystoma,  Abdominal  and  Vaginal. 

Salpingo-oophorectomy. — It  is  still  convenient  to  distinguish  thus 
the  operation  for  ovarian  cystoma  (of  large  size)  from  that  for  other 
morbid  conditions  of  the  adnexa. 

On  what  grounds  are  we  justified  in  removing  the  ovaries  and 
appendages  for  disease  in  the  ovaries  or  Fallopian  tubes?  We 
meet  with  cases  in  which  every  known  means  has  been  tried  to 
combat  pain,  to  enable  a  patient  to  walk,  to  tide  over  with  safety 
menstrual  periods,  to  reduce  localized  swellings  which  recur  in  the 
broad  ligaments  and  pelvic  peritoneum  ;  in  short,  to  render  life 
bearable  and  enable  the  patient  to  move  about  in  society. 

In  many  of  these  cases  we  can  date  the  commencement  of  trouble 
to  an  acute  attack  of  perimetritis.  There  may  have  been  a  latent 
gonorrhoea.  In  others  we  find  nothing  definite  :  some  history  of 
dysmenorrhoea,  menorrhagia,  periodical  peritoneal  attacks,  sterility 
and  futile  operations  on  the  cervix,  with  all  those  symptoms  which 
are  attendant  upon  "  chronic  ovaritis."  Examination  by  the  vagina 
reveals,  at  the  most,  a  sensitive  uterus,  or  one  drawn  out  of  place  by 
an  old  adhesion,  a  displaced  or  painful  ovary,  or  some  localized 
swelling.  It  is  in  such  women  that  the  question  of  salpingo- 
oijphorectomy  arises. 

We  have,  however,  to  consider  the  inherent  difficulties  of  an  exact 
diagnosis.  No  man  has  shown  this  latter  contingency  more  clearly 
than  Tait  himself.  He  again  and  again  exhibited  specimens  of 
ovaries  and  diseased  Fallopian  tubes,  removed  under  circumstances 
far  difierent  from  those  for  which  this  operation  was  originally  pro- 
posed, and  even  carried  out.  A  tense  and  distended  Fallopian  tube 
has  been  mistaken  in  vaginal  examination  for  fibromyoma ;  hydro- 
and  pyo-salpinx  have  been  mistaken  for  ovarian  tumour,  and  vice 
versd.     And  it  must  always  occur,  even  to  the  most  distinguished 


780  DISEASES  OF   WOMEN. 

surgeons,  that  only  an  exploratory   operation   can   determine  the 
extent  and  nature  of  the  disease. 

Importance  of  Complete  Eemoval. — In  a  letter  to  the  author  on  the  subject, 
Tait  said :  '  Concerning  the  removal  of  the  uterine  appendages,  the  points 
that  I  want  to  lay  stress  upon  are,  chiefly :  Firstly,  that  no  operation  for  the 
removal  of  the  uterine  appendages  ought  to  he  left  unfinished.  The  oppro- 
hrium  of  all  this  class  of  work  will  in  the  future  he  unfinished  operations. 
They  are  far  more  difficult  than  any  other  operations  in  abdominal  surgery, 
and  therefore  their  undertaking  should  he  limited  to  a  relatively  small  numher 
of  men.  Secondly,  that  if  for  chronic  inflammatory  disease  it  is  necessary  to 
remove  one  set  of  appendages,  both  ought  to  be  removed,  because  otherwise 
a  second  operation  will  in  all  probability  be  required,  and  these  second 
operations  are  far  more  dangerous  than  the  first.' 

So  far  as  the  incompleteness  of  the  operation,  all  experienced  operators  will 
confirm  Tait's  dictum.  Salpingo-oophorectomy  may  be  either  one  of  the  most 
simple  or  most  difficult  operations,  according  to  the  complications  met  with — 
adhesions,  blood  cysts,  myomata,  purulent  collections,  displacements  of  the 
adnexa,  intestinal  complications,  etc.  His  second  conclusion  is  not  now 
generally  accepted,  and  no  surgeon  would  be  justified  in  removing  both 
adnexa  unless  there  were  unmistakable  proofs  of  disease  in  both.  Also,  no 
surgeon  is  justified  in  removing  an  ovary  on  which  a  complete  conservative 
operation  can  be  performed,  and  which  will  preserve  even  a  small  portion  of 
healthy  gland,  the  Fallopian  tube  heing  also  healthy.  It  is  of  the  greatest 
importance  to  a  woman  not  to  sacrifice  the  whole  of  an  ovary  if  part  can  be 
retained.  It  is  equally  important  to  save  the  healthy  Fallopian  tube,  and  so 
to  deal  with  the  oviduct  as  to  leave,  it  patent  and  capable  of  discharging  its 
functions.* 

Cases  Illustrative  of  the  Value  of  Conservative  Operations. 

Pregnancy  after  Oophorectomy  and  Removal  of  an  Ovarian  Blood 
Cyst,  the  other  Ovary  being  atrophied  and  adherent.! 

An  ovarian  blood  cyst  was  removed  from  a  patient  under  the  following  ch- 
cumstances.  She  was  thirty  years  of  age  at  the  time  of  operation,  and  had  been 
married  for  seven  years,  never  having  conceived.  At  the  age  of  twenty,  she 
had  an  attack  of  pelvic  peritonitis.  The  following  year  she  had  a  recurrence, 
which  spread  into  general  peritonitis  of  a  most  alarming  character,  and  nearly 
proved  fatal ;  six  months  later  there  was  another  attack.  On  and  off  after 
this  she  sufl:ered  from  abdominal  and  pelvic  pains,  but  gradually  improved. 
After  marriage  she  consulted  me  for  a  severe  cervical  erosion,  and  there  was 
then  decided  enlargement  of  the  left  ovary.  The  erosion  was  cured,  and  she 
had  a  course  of  treatment  at  Woodhall  Spa.    The  recurrent  pains  from  which 

*  For  conservative  operations  on  the  adnexa,  see  conclusion  of  chapter  on  the 
Fallopian  Tubes.      See  also  p.  784. 

t  This  case  shows  the  discrimination  that  must  be  exercised  before  both 
appendages  are  ablated. 


\AFFECTIONS  OF  THE   OVAELES,  781 

she  had  sull'erod  more  or  less  for  j'ears  now  became  more  constant,  and  at 
last,  especially  at  the  right  side,  were  incessant.  Salpingo-oophorectomy  was 
performed  a  year  after  her  first  attack  of  peritonitis.  On  opening  the  abdomen, 
the  peritoneum  was  found  extensively  adherent  to  the  bowel,  which  latter 
was  opened  for  a  short  distance.  Another  opening  had,  in  consequence,  to 
be  made  in  the  left  inguinal  region.  The  sac  of  the  left  ovary  was  found 
about  the  size  of  an  orange,  and  full  of  blood,  completely  bound  down  by 
adhesions,  which  were  separated  with  difficulty.  The  cyst  with  the  left  tube 
was  removed  entire.  On  seeking  for  the  rifjht  ovary,  it  could  not  le  found, 
and  it  ivas  only  after  considerable  searching  that  it  was  detected  firmly 
attached  to  the  pelvic  luall,  to  which  it  was  fixed  by  adhesions,  and  con- 
siderably reduced  in  size.  The  prudence  of  removing  it  was  discussed,  but  in 
the  face  of  the  protracted  operation  and  the  exhausted  condition  of  the  patient, 
it  was  considered  wiser  not  to  subject  her  to  any  additional  shock,  which  the 
attempted  removal  of  the  firmly  adherent  and  apparently  atrophied  ovary 
would  involve.  She  made  an  uninterrupted  recovery.  Menstruation  con- 
tinued, and  on  and  off  she  suffered  again  from  pelvic  pains  in  the  right  side, 
and  a  year  after  operation  there  was  a  distinct  swelling  to  be  felt  in  the  right 
broad  ligament.  This  disappeared,  but  there  was  always  more  or  less  distress 
and  pain,  especially  with  the  menstrual  periods.  Three  years  from  the  date 
of  the  operation  she  became  pregnant.  She  was  delivered  of  a  male  child 
by  Dr.  Taylor,  of  Richmond.  The  surviving  ovary  has  frequently  given 
trouble  since  then,  but  nothing  as  yet  has  occurred  to  justify  its  removal. 


Case  of  Twins  after  Salpingo-oophorectomy  and  Resection  of 
the  other  Ovary, 

The  patient,  aged  26,  who  bad  had  five  pregnancies,  with  labour  at  full 
term,  fii-st  consulted  me  three  years  since.  She  was  then  suffering  from  all 
the  symptoms  attendant  upon  chronic  suppurative  endometritis.  There  was 
a  very  profuse  discharge,  with  an  extensive  and  deep  cervical  erosion.  She 
had  been  treated  for  the  erosion  and  endometritis  for  some  time  before  I  saw 
her.  Both  ovaries  were  enlarged  and  painful,  the  left  especially  so.  The 
uterus  was  subjected  to  most  thorough  curetting,  with  the  application  of 
chromic  acid  internally,  and  nitric  acid  to  the  eroded  surface,  the  result  being 
a  complete  cure  of  the  endometritis  and  erosion.  Pelvic  pain,  however,  still 
continued,  with  difficulty  of  locomotion,  and  a  year  subsequently  I  removed  a 
large  cystic  ovary  with  a  thickened  and  dilated  tube,  and  resected  the  other 
ovary,  which  was  studded  with  small  cysts.  She  quickly  recovered  from  the 
operation,  but  for  some  time  the  course  of  the  case  was  not  very  satisfactory, 
as  she  still  complained  of  pelvic  pain,  and  there  was  sensitiveness  of  the 
remaim'ng  ovary.  However,  sixteen  months  after  the  operation,  she  was 
confined  of  twins,  under  the  care  of  Dr.  Frederick  Evans,  of  Cardiff.  Her 
labour  was  a  very  quick  one.  The  sex  of  both  children  was  female,  and 
there  were  two  amniotic  sacs  and  two  placentae.* 

*  See  chapter  on  Tuberculosis  for  similar  casep. 


782  DISEASES  OF   WOMEN. 

Repeated  Pregnancies  after  Salpingo-obphorectomy  and 
Ventrofixation  of  the  Uterus. 

Patient,  aged  26,  ten  weeks  after  marriage  had  had  an  accident  causing 
miscarriage,  for  which  she  was  casually  treated,  being  in  bed  for  two  days 
only.  Since  then  she  had  never  been  weU — sacral  aching,  fatigue,  great  pain 
before  and  during  the  periods,  walking  producing  much  pelvic  distress ;  had 
consulted  two  specialists ;  one  put  her  under  the  '  rest '  cure  ;  the  other  told 
her  to  forget  her  pain  and  take  a  long  sea  voyage.  She  went  to  Australia, 
and  suffered  much  increase  of  trouble  during  the  voyage,  and  was  there  laid 
up.  She  came  home  as  soon  as  she  could  travel,  much  the  worse  for  her 
trip.  Sis  months  after  this.  Dr.  W.  H.  Bourke,  whose  patient  she  was, 
found  a  retroflexed  uterus  with  the  left  ovaiy  in  Douglas's  pouch,  swollen, 
not  movable,  and  very  tender.  Finding  it  impossible  to  keep  a  pessary  of 
any  kind  in  the  vagina,  and  no  good  resulting  from  palliative  treatment,  he 
advised  operation,  but  was  overruled  by  three  consultants  consecutively.  He 
then  treated  the  unhealthy  state  of  the  os  and  cervix  in  the  hope  of  pro- 
ducmg  conception,  which  fortunately  occurred,  and  he  safely  delivered  her 
at  full  term.  In  spite  of  every  precaution,  after  delivery  the  uterus  returned 
to  its  former  position,  and  the  ovary  continuing  to  give  trouble,  life  became 
a  burden  to  her.  He  again  advised  operation,  and  had  consultations  with 
three  other  specialists,  who  were  not  in  favour  of  it,  though  there  was  no 
alternative  save  chronic  invalidism.  At  his  request,  I  saw  the  patient,  and 
immediately  operated,  removing  a  large  left  cj'stic  ovary  and  performing 
ventrosuspension.  He  summarizes  the  result  in  the  following  words  :  '  The 
result  has  been  perfect  from  a  surgical,  and  exceedingly  so  from  a  matri- 
monial point  of  view,  for  the  patient  has  been  thrice  confined  at  full  term 
of  healthy  children,  without  the  smallest  complication.  One  conception, 
however,  ended  in  a  miscarriage.'  The  uterus  has  all  through  maintained 
its  normal  position. 

I  have  had  several  other  equally  interesting  cases,  in  which  there  were 
con-esponding  successful  issues  from  various  conservative  operations. 

Indications  for  Salpingo-oophorectomy. — In  view  of  the  differences 
of  opinion,  both  as  regards  the  justification  for,  and  the  permanent 
benefit  derived  from,  the  operation  of  removal  of  the  appendages, 
it  may  be  well  first  to  recapitulate  briefly  the  indications  which  in 
the  author's  opinion  justify  the  operation  of  salpingo-oophorectomy : — 

1.  Certain  forms  of  uterine  myomata  which  threaten  life.* 

2.  Diseased  conditions  of  the  ovaries  that  resist  all  palliative 
treatment,  and  which  both  embitter  and  endanger  life. 

3.  Those  conditions  of  the  Fallopian  tubes,  isolated  or  associated, 
which,  are  not  amenable  to  other  means  of  cure,  and  in  which  sudden 
danger  to  life  may  arise,  or  where  there  is  such  constant  suffering  as 
to  make  life  miserable. 

*  See  chap.  xxv..  on  Salpingo-oophorectomy,  for  Fibromyomata. 


AFFECTIONS  OF  THE   OVARIES.  783 

4.  Certain  cases  of  pelvic  suppuration  when  the  adnexa  are 
in%-olved.  These  have  already  been  dealt  with  in  treating  of  pelvic 
suppurations.* 

5.  Ovarian  tubo-ovarian  and  tubal  ectopic  gestation. 

6.  Some  incurable  cases  of  dysmenorrhcea,  unaffected  by  any 
course  of  palliative  treatment,  or  milder  operative  measures  under- 
taken for  the  relief  of  pain,  and  attendant  neuroses.  In  these  cases 
the  association  of  any  of  the  previous  conditions  adds  to  the 
expediency  and  justification  of  operation. 

7.  Those  cases  of  epilepsy  and  hystero-epilepsy  in  which  there 
is  clear  evidence  of  correlation  between  these  attacks  and  such 
affections  as  ovaritis,  ovarian  displacements,  enlargements,  or 
degenerations,  with  or  without  accompanying  tubal  pathological 
conditions. 

8.  The  operation  may  be  indicated  in  certain  cases  of  disordered 
mentalization  where  disease  of  the  adnexa  is  determined  by  examina- 
tion under  anaesthesia. 

Both  ovaries  and  both  Fallopian  tubes  should  be  removed  (a) 
where  the  operation  is  performed  for  the  arrest  of  growth  and 
haemorrhage  in  myoma ;  (b)  in  dysmenorrhoia  where  the  object  is  to 
produce  premature  change  of  life  ;  (c)  in  neuroses  associated  with 
dysmenorrhcea,  recurrent  ovaritis,  displaced  and  sensitive  ovaries ; 
(d)  where  both  ovaries  and  both  tubes,  or  one  ovary  and  both  tubes, 
are  so  diseased  that  no  conservative  operation  is  feasible  or 
advisable. 

The  operation  is  only  to  be  undertaken  after  full  consideration, 
and  when  the  consequences  are  placed  before  the  patient  and  her 
immediate  relatives,  and  her  free  consent  obtained. 

Nor  should  the  patient  be  allowed  to  believe  that  salpingo- 
oophorectomy  is  a  simple  step.  On  the  contrary,  as  has  been  said, 
peritoneal  adhesions  to  the  intestines,  deep  pelvic  attachments  of 
the  ovaries  and  tubes,  ovarian  cystic  collections  of  blood  and  pus, 
pyo-  and  hsemato-salpinx,  may  render  it  most  difficult  to  remove 
the  appendages  completely  and  aseptically. 

(The  special  indications  for  the  step  in  the  instance  of  uterine 
myomata  have  been  already  fully  and  separately  dealt  with.) 

It  is  due  to  Mary  Dixon  Jones,  of  Xew  York,  to  refer  to  her 
opinions  on  tliis  question — one  of  such  vital  moment  to  her  own  sex. 

Enumerating  the  conditions  in  which  the  operation  should  be  performed, 
*  See  chapter  on  Pelvic  Inflainmatiun. 


784  DISEASES   OF    WOMEN. 

she  includes  the  following — Plastic  peritonitis  with  pseudo-membranous 
adhesions ;  purulent  peritonitis,  with  abscess,  the  consequence  of  adnexal 
disease ;  gyroma,  with  varicose  states  of  the  nerve  fibres ;  gonorrhceal  salpin- 
gitis with  pyo-salpinx ;  sarcoma  and  carcinoma  of  the  ovary,  with  other  solid 
tumours  of  the  gland.  She  does  not  approve,  save  where  there  is  hopeless 
disease  of  the  organs  themselves,  of  removal  of  the  adnexa  for  any  neurotic 
condition,  constitutional  disturbance,  or  for  any  reason  save  incui-able  disease. 
She  insists  that  it  is  not  always  possible  to  tell  by  the  ocular  appearances 
whether  an  ovary  is  sufficiently  diseased  or  not  to  warrant  removal,  and  she 
quotes  cases  in  which  dependence  upon  naked-eye  appearances  would  have 
led  to  the  most  serious  consequences,  both  endothelioma  and  cancer  being 
present,  though  not  suspected.  Some  of  the  most  serious  cases  she  has  ever 
operated  upon  gave  no  naked-eye  evidences  of  disease.  In  the  majority  of 
cases  of  pyo-salpinx,  extra-uterine  pregnane}'',  hydro-  and  hgemato-salpinx, 
operation  is  indicated.  As  she  well  says,  it  is  only  by  accident  that  such 
patients  ever  become  well  without  operation,  and  the  risks  run  by  postpone- 
ment are  far  greater  in  themselves  than  those  run  by  operation.  Nor  is  it  to 
be  lost  sight  of  that  the  evil  consequences  of  long-continued  pelvic  disease, 
with  all  its  attendant  troubles,  reduce  the  patient's  chances  of  recovery  from 
operation  while  they  increase  its  difficulties.  Aglutinations  of  the  pelvic 
viscera,  pus  sacs,  with  purulent  infiltration,  are  mingled  with  organized 
adhesions,  difficult  to  break  up,  and  which  leave  extensive  raw  surfaces,  the 
sources  of  future  adhesions.  '  The  policy  of  delay  works  badly  in  every  way, 
women  continue  to  be  invalids,  many  die  from  inter- current  attacks  of 
peritonitis,  and  those  who  live  on  do  so  with  lessened  chances  of  recovery 
when  they  submit  to  operation,  and  greatly  increased  risks  of  but  partial 
restoration  to  health.'  * 

(The  operation  of  abdominal  salpiago-oophorectomy  has  been 
described  in  chap,  xxv.,  on  the  Operative  Treatment  of  Myoma  of 
the  Uterus.) 

In  a  paper  on  conservative  operations  on  the  adnexa  f  I  entered  into  the  " 
question  of  the  risk  following  the  operation  of  abdominal  salpingo-oophorectomy 
in  complicated  and  uncomplicated  cases-: — 

*  I  have  recently  removed  both  adnexa  in  two  cases  where,  on  exposing  the 
pelvic  cavity,  nothing  was  to  be  seen  save  the  uterus,  which  was  firmly  adherent 
posteriorly.  In  one  the  ovaries  and  tubes  were  quite  concealed  from  view  by  an 
effusion  in  which  they  were  imbedded — a  fluctuating  cyst  adherent  to  the 
pelvic  wall  could  be  detected  at  the  right  side.  This  proved  to  be  a  blood  sac 
of  the  ovary.  This  patient  suffered  also  from  an  enormously  dilated  stomach, 
necessitating  its  washing  out  under  an  anaesthetic.  She  is  making  an  excellent 
recovery. 

Lavage  of  the  stomach  has  been  before  referred  to.  In  cases  of  post-operative 
vomiting  the  washing  out  of  the  stomach  often  gives  the  greatest  relief.  It 
may  be  done  twice  daily.  Quinine  and  boric  acid  in  1  in  5000  formalin  is 
a  useful  solution. 

t  Brit.  Gyn.  Jour.,  Feb.,  1903. 


AFFECTIONS   OF  THE   OVAMJES.  785 


Operation  in  Uncomplicated  and  Complicated  Cases. 

By  "uncomplicated,"  I  mean  plain,  straightforward  cases  in  which  the 
operation  can  be  completed  Avithout  any  unusual  risks  from  adhesions, 
hiumorrhage,  the  presence  of  septic  fluids,  or  such  a  low  state  of  vitality  or 
deficient  vital  resistance  as  to  render  the  risk  of  any  operative  interference 
disproportionate  to  its  severity.  By  "  complicated,"  I  understand  those 
cases  in  which  the  operator  meets  with  old  and  extensive  adhesions,  and 
organised  attachments  to  surrounding  parts,  the  presence  of  septic  fluids,  the 
pi'olongation  of  an  operation  in  consequence  of  the  complications  being 
bilateral,  the  extra  shock  involved  both  by  this  and  possibly  by  hemorrhage, 
and  difficulty  met  with  in  delivering  the  tumour.  To  these  unpropitious 
conditions  we  may  add  the  temperament  of  some  patients,  restless,  appre- 
hensive, hysterical  and  impatient  of  pain.  In  the  first  class  of  case  I  do  not 
think  it  is  an  exaggeration  to  say  that  the  mortality  (with  our  improved 
methods)  of  simple  salpingo-oophorectomy  is  not  more  than  1  to  2  per  cent. 
For  my  own  part,  taking  all  the  cases  of  salpingo-oophorectomy  I  have 
performed  (I  cannot  say  Jiow  many),  complicated  or  otherwise,  I  have  only 
lost  one,  and  that  I  attributed  partly  to  some  operative  bunghng.  The  patient 
had  been  ailing  for  years ;  had  mitral  valvular  disease,  and  was  very  anasmic. 
There  was  adnexal  trouble,  associated  with  great  agony.  In  consequence 
of  her  cardiac  complication  I  put  off  operation.  At  last  there  was  no 
alternative,  and  I  removed  a  blood-sac  from  the  right  side,  and  found  another 
similar  sac  at  the  left.  Both  were  bound  down  by  adhesions.  In  freeing 
these  and  in  bringing  the  adnexal  mass  to  the  surface  I  had  great  difficulty, 
and  was  tempted  to  seize  the  tumour  with  a  tenaculum.  In  the  effort  I  must 
have  pierced  a  large  venous  sinus  in  the  broad  ligament.  Immediately  the 
pelvis  tilled  with  blood,  and  I  had  the  greatest  difficulty  in  arresting  the 
hjBmon'hage.  I  left  a  Miculicz  tampon  in  the  pelvis,  and  a  temporary  clamp. 
There  was  no  further  haemorrhage,  but  she  never  recovered  the  shock.  This 
has,  so  far,  been  my  first  and  last  death  from  salpingo-oophorectomy. 

If  we  now  endeavour  to  determine  the  percentage  mortality  in  the  com- 
plicated cases,  we  have  a  difficult  task.  Tait  said  that  oophorectomy  might 
be  one  of  the  simplest  and  easiest,  or  one  of  the  most  difficult,  operations  in 
surgery,  and  so  it  is.  Still,  I  do  not  think  that  we  can  assign  a  larger 
mortality,  even  in  complicated  cases,  than  5  per  cent.  Is  there  any  operative 
procedure  of  equal  severity  in  the  whole  domain  of  surgery  of  which  more 
favourable  results  can  be  quoted  than  this  ?     I  am  ignorant  of  any. 

Bear  in  mind  that  the  great  majority  of  these  operations  are  imdertaken 
for  utterly  incurable  conditions,  or,  at  the  best,  in  states  where  there  are 
smouldering  volcanoes  ready  to  burst  into  activity  at  any  moment  under  the 
slightest  provocation,  and  commonty  rendering  the  woman's  life  a  misery  to 
her.  This,  then,  is  our  position  to-daj^  in  regard  to  salpingo-oophorectomy — 
it  challenges  competition  with  any  other  surgical  major  operation  for  rapidity 
of  execution,  speediness  of  recovery,  and  completeness  of  cure.  Personally, 
I  should  let  no  sentimental  considerations  or  problematical  sexual  consequences 
stand  in  my  way  of  rescuing  a  woman  from  misery,  or  saving  her  life — she 
knowing  to  the  fullest  the  consequences  of  the  step  about  to  be  taken  and 

3   E 


786  DISEASES   OF   WOMEN. 

acquiescing- in  its  completion.     It  goes  without  saying  that  the  most  gratifying 
results  follow  from  thorough  and  complete  operations. 

There  must  ever  be  a  large  pi'oportion  of  cases  in  which  the  complete 
removal  of  both  adnexa  is  indicated.  Cystic  and  other  tumours,  pus  cavities 
and  sacs,  if  present,  immediately  determine  this.  There  is  another  class  in 
which  the  examination  of  the  unaffected  adnexa  on  one  side  proves  them  to 
be  normal  and  healthy,  aiid  in  tohich  no  question  of  their  removal  can  arise. 
There  is  a  third  where  partial  disease  aifects  the  tube  or  ovary,  or  both,  either 
on  the  one  side  or  on  the  two.  The  question  is.  How  are  we  to  deal  with 
such  cases — (a)  when  the  organs  at  either  side  are  sufficiently  free  from 
disease  to  justify  attempts  at  conservative  operations  ;  (b)  when  the  partially 
affected  adnexa  on  one  side  are  associated  with  organs  so  seriously  afi'ected 
on  the  other  as  to  call  for  the  removal  of  the  latter. 

We  will  deal  with  the  first  contingency.  I  take  it  that  no  one  will  remove 
adnexa  in  whole  or  part  in  which  such  operations  as  ovarian  resection  or 
salpingostomy  offer  a  reasonable  hope  that  a  cure  will  follow  their  performance. 
This  would  apply  to  simple  cystic  states,  small  blood-cysts,  localized  suppura- 
tive foci  in  the  ovary,  or  localized  and  circumscribed  distension  and  stricture 
of  the  Fallopian  tube. 

Here  careful  ablation  of  the  diseased  parts  and  plastic  operations  afford  the 
woman  all  the  protection  she  can  expect  against  a  second  operation.  Should 
she,  however,  insist  that  in  the  event  of  its  being  found  that  there  is  a 
reasonable  doubt  of  ultimately  saving  the  organs,  the  adnexa  are  to  be 
removed,  then  I  think  she  is  entitled  to  the  benefit  of  that  doubt,  and  should 
not  be  subjected  to  the  risk  and  ordeal  of  a  second  operation. 

The  second  contingency  is  that  in  which  it  is  imperative  to  remove  the 
adnexa  of  one  side,  and  where  at  the  time  of  operation  those  of  the  other 
are  found  to  be  partially  affected  in  any  of  the  ways  that  I  have  mentioned. 
Is  it  here  the  best  course  to  perform  some  conservative  operation  and  return 
the  adnexa,  or  to  ablate  them  ?     These  cases  bear  on  the  reply. 

The  first  was  operated  upon  by  me  for  adnexal  disease,  and  the  affected 
tube  and  ovary  were  removed.  She  was  a  married  woman,  aged  26. 
Constant  and  uncontrollable  vomiting  necessitated  operation.  All  vomiting 
ceased  from  the  time  of  its  performance,  and  the  patient  was  apparently 
restored  to  perfect  health.  The  left  adnexa  were  removed.  The  cyst  was  the 
size  of  a  small  orange,  and  there  had  been  intra- cystic  hsemon'hage  into  the 
tumour.  At  the  same  time  the  opposite  ovary  was  resected,  and  a  fair-sized 
cyst  ablated,  while  some  smaller  ones  were  punctured.  Eight  months  subse- 
quently she  contracted  influenza,  and  after  this  similar  attacks  of  vomiting  to 
those  she  had  suffered  from  before  her  last  operation  commenced.  There  was 
also  constant  headache  and  severe  pain  in  her  right  side.  She  had  great 
difficulty  in  walking,  and  there  was  incontinence  of  urine.  I  performed  a  second 
operation  one  year  and  eight  months  after  the  first,  when  the  right  adnexa 
were  removed.  There  was  cystic  degeneration  of  the  right  ovary,  the  tube 
bemg  distended,  and  there  was  a  double  cyst  in  the  broad  ligament.  She 
made  a  rapid  recovery.  Some  six  months  after,  hsemorrhage  recurred  from 
the  uterus,  and  as  it  persisted  I  performed  cm-ettage,  and  the  curettings 
were    pronounced   to    be    of   an   adenomatous    nature.      The   haemorrhage 


AFfECTWyS   OF   THE   OVAlilES.  787 

ceased  after  the  operation,  but  returned  again  witli  increased  severity. 
Tlie  third  cu'hotoiuy  was  done  ten  months  subsequently.  I  found  a  third  cyst 
in  the  broad  ligament,  which  I  removed.  I  removed  the  uterus  by  the  supra- 
vaginal method,  close  to  the  vaginal  vault.  This  patient  has  now  become  a 
robust  woman. 

A  patient,  aged  32,  had  been  operated  upon  by  another  surgeon,  un  able 
gynecologist,  live  years  previously  for  a  hydro-salpinx  at  the  left  side,  the  size 
of  the  fist,  by  a  posterior  colpotomy.  The  operation  was  a  simple  one.  At 
the  time  both  ovaries  seemed  on  inspection  to  be  healthy,  except  for  the 
appearance  of  several  small  cysts,  which  were  punctured.  Both  ovaries  were 
returned.  The  uterus  was  healthy  in  size  and  position.  The  condition 
reported  to  me  when  I  saw  her  was — '  Uterus  normal,  riglit  ovary  normal,  left 
enlarged  and  painful.'  There  was  a  serious  falling  off  in  weight  and  general 
health.  On  examination  an  adnexal  tumour  was  found  filling  the  pouch  of 
Douglas.  Operation  revealed  a  left  ovary  and  tube  fixed  and  surrounded  by 
adhesions.  At  the  right  side  there  was  an  ovarian  cyst  about  the  size  of  an 
orange,  and  an  enlarged  tube — a  hsemato-salpinx.  The  right  adnexa  were 
removed,  and  the  patient  is  now  quite  a  different  woman,  notwithstanding  the 
added  complication  of  a  movable  and  enlarged  kidney.  The  left  ovary 
continues  to  discharge  its  function. 

Here  are  two  operations  in  which  a  complete  operation  on  both  adnexa  in 
the  first  instance  would  have  saved  a  second,  as  well  as  great  suffering,  if  not 
risk.  I  have  since  had  under  my  care  three  cases  in  which  oophorectomy 
at  one  side,  resection  at  the  other,  and  ventro-suspension,  were  performed  by 
me,  and  in  all  these  an  adnexal  tumour  required  removal. 

The  fact  remains  that  no  surgeon  can  tell  what  percentage  of  such 
conservative  steps  may  bequeath  a  demand  for  secondary  interference.  And 
the  very  nature  of  the  affections  to  which  these  organs  are  subject  (I  speak 
more  particularly  of  the  ovaries)  renders  this  recurrence  a  probability. 
Nothing  is  more  tempting  than  to  do  a  neat  salpingostomy  and  resection  of 
an  ovary.  I  am  fully  alive  to  the  other  side  of  the  question,  namely,  the 
desire  to  preserve  the  adnexa  at  all  hazards.* 

Vaginal  Salping-o-oophorectomy. 

Anterior  Colpotomy — A.  Martin's  Operation. — If  the  anterior 
route  be  selected,  the  operation  is  performed  thus :  The  genitals 
having  been  shaved,  and  the  thorough  sterilization  of  the  vagina 
secured,  the  woman  is  placed  in  the  usual  position.  The  uterus  is 
drawn  well  down,  and  its  length  and  position  are  ascertained  by 
the  sound.  The  attachment  of  the  bladder  and  its  relation  to  the 
uterus   are   determined   in   the  same  manner.     The  cervix  is  now 

*  That  the  conservative  resection  of  an  ovary  which  has  been  in  part  diseased 
is  not  without  dangers,  is  shown  by  a  case  of  P'ischer's  (Centralh.  f.  Gyn.,  1900, 
No.  31),  in  which  the  remnant  of  a  gland,  jjartly  removed  with  its  fellow  for  the 
production  of  the  menopause,  developed  a  large  bilocular  cyst. 


DISEASES   OF   WOMEN. 


caught  by  two  vulsella,  which  are  held  in  one  hand.  Orthmann's 
combination  of  uterine  sound  with  claw  forceps  is  preferable,  if  it 
be  at  hand  (Fig,  188).  The  sound  extremity  is  passed  into  the 
uterus,  and  the  neck  is  seized  by  closing  the  instrument  so  that  the 
claw  fixes  the  cervix  externally.  With  this  the  uterus  can  be 
drawn  well  down  so  as  to  place  it  and  the  anterior  cul-de-sac  on  the 
stretch.  An  assistant  now  passes  a  vaginal  retractor  below  the 
urethra  and  draws  it  up  out  of  the  way,  and  with  the  same  hand 
he  holds  a  pipette  so  as  to  direct  an  irrigating  stream  on  the  part, 
allowing  this  to  play  continuously  during  the  operation.  The 
flushing  vaginal  retractor  (Fig.  105)  is  the  best  means  of  irriga- 
tion we  possess  for  vaginal  operations.  The  uterus  being  thus  fixed 
and  stretched  with  one  hand,  with  the  other  the  operator  makes  an 
incision  directly  in  the  middle  line  through  the  mucous  membrane. 
This  is  then  reflected  up  with  a  few  strokes  of  the  knife.  This  is 
Martin's  longitudinal  incision,  but  many  prefer  the  transverse 
incision  through  the  mucous  membrane  at  the  utero-vaginal  junc- 
tion. The  sub-mucous  tissue  is  now  cautiously  divided,  and  the 
separation  of  the  bladder  is  effected  by  the  fingers,  point  of  curved 
scissors,  or  cautious  dissection  with  a  scalpel.  Meanwhile,  the 
retractor  is  carefully  used  to  protect  the  bladder,  and  keep  it  out 
of  harm's  way.  The  peritoneum  is  now  sought  for,  caught  with 
dressing-forceps,  and  divided  with  scissors,  the  blades  of  which  are 
opened  so  as  to  enlarge  the  incision,  and  the  opening  is  further 
increased  in  size  with  the  finger.  Martin's  conical  retractor  is 
slipped  underneath  the  peritoneum  so  as  to  protect  the  bladder 
completely.  The  perineal  retractor  may  now  be  withdrawn,  and  the 
index  finger  is  carried  into  the  peritoneal  cavity.  The  adnexa  and 
broad  ligaments  at  either  side  are  carefully  examined,  the  presence 
of  adhesions  and  the  size  of  the  ovaries  and  tubes  being  determined. 
The  perinea]  retractor  is  now  replaced,  and  the  uterus  is  seized  and 
brought  into  the  vagina.  The  ovary  and  tube  at  either  side  are 
next  sought  for,  seized,  brought  into  view,  and  examined.  They 
are  then  removed,  or  punctured  if  cystic,  or  resected.  If  the  adnexa 
of  either  side  be  healthy,  these  are  returned.  It  may  not  be  neces- 
sary to  bring  the  uterus  forwards,  for  the  adnexa  can  be  hooked  down 
with  the  finger,  or  the  ovarian  clamp-forceps  can  be  used  to  seize 
the  ovary  and  bring  it  into  the  vagina.  The  presence  of  adhesions, 
cysts,  solid  growths  of  the  ovary,  pus  sacs,  and  myomatous  tumours, 
will  add  considerably  to  the  risk  and  difiiculty  of  the  operation. 
Here  adhesions  have  to  be  carefully  separated,  cysts  punctured,  and 


AFFECTIONS   OF  THE   OVARIES.  78! t 

in  some  cases  it  may  be  necessary,  as  in  tubo-ovarian  ectopic  gesta- 
tion, to  combine  an  abdominal  operation  with  the  vaginal.  Bisection 
of  the  uterus  by  any  of  the  methods  already  described  may  be 
demanded.  It  is  just  when  such  conditions  are  present  that  a 
careful  previous  diagnosis  must  be  made,  and  that  the  abdominal 
route  will  be  found  preferable  to  the  vaginal. 

Posterior  Colpotomy. 

The  majority  of  gynaecologists  prefer  the  posterior  to  the  anterior 
vaginal  route  in  exploration  of  the  pelvic  viscera,  and  for  operations 
on  the  adnexa.  It  is  without  doubt  the  operation  of  selection. 
Palpation  is  easier,  and  the  adnexa  ai'e  more  within  reach,  and  are 
more  readily  drawn  into  the  vagina,  while  drainage,  when  required, 
is  better  carried  out  from  the  pouch  of  Douglas.  Also  the  broad 
ligaments  can  be  more  completely  traced,  and  any  effusions  or  tumours 
in  them  defined. 

Operation, — The  patient  being  in  the  usual  position,  and  aseptic 
precautions  having  been  taken,  a  large  perineal  retractor  is  intro- 
duced, and  the  cervix  is  seized  with  two  tenacula,  or  Orthmann's 
instrument  may  be  employed  to  depress  and  pull  it  forwards.  The 
recto-vaginal  fold  is  incised  transversely  a  few  millimetres  behind 
its  insertion  with  the  neck.  The  incision  is  curved  with  the 
concavity  in  front,  measuring  some  six  centimetres  in  length.  The 
wound  may  be  further  freed  with  a  few  strokes  of  a  curved  blunt- 
pointed  scissors.  The  peritoneal  cul-de-sac  is  now  sought  foi', 
caught  in  a  forceps  and  incised.  By  diverging  the  blades  of  the 
scissors  the  opening  is  enlarged,  and  the  right  index  finger,  intro- 
duced into  the  wound  and  being  carried  straight  to  the  posterior 
surface  of  the  uterus,  acts  as  a  guide  to  the  adnexa. 

These  are  drawn  into  the  wound  either  by  the  aid  of  the  index 
and  middle  finger,  or  with  the  ovarian  forceps.  Should  there  be 
adhesions  which  prevent  this,  the  forceps  held  in  the  right  hand 
grasps  the  left  adnexa  ;  and  the  fingers  of  the  left  hand,  carried 
through  the  peritoneal  opening,  cautiously  separate  the  adhesions 
one  by  one.  When  the  adnexa  are  thus  drawn  out,  the  pedicle  is 
tied  en  masse,  or  is  transfixed  with  a  curved  needle  and  tied  in  the 
usual  manner  in  separate  portions.  It  may  temporarily  be  held 
with  clamp  forceps. 

In  some  cases,  if  there  be  great  difficulty  in  restraining,  and  fear 
of  subsequent,  haemorrhage,  the  clamps  may  be  allowed  to  remain 


790 


DISEASES  OF  WOMEN. 


on;  especially  is  this  so  if  the  broad  ligaments  be  short,  and 
have  been  much  dragged  about  or  injured.  Also  there  are  cases 
in  which,  when  the  bleeding  continues  from  a  high  source,  it  is  most 
difficult  to  pass  a  ligature,  and  here  permanent  forcipressure  is  the 
more  safe  plan  to  adopt. 

The  same  procedure  is  applied  at  the  opposite  side  when  both 
adnexa  are  diseased. 


Fig.  521. — Ixcisioxs  of  Saxger  foe  Veetical,  axd  0.  Zuckeekaxdl  for 
Tkansveese,  Perineotomy. 

The  difficulty  most  frequently  met  with  in  posterior  colpotomy  is 
adhesions  closing  Douglas's  pouch ;  these  may  be  so  extensive  as  to 
obliterate  the  sac,  and  render  the  uterus  immovable.  Such  immo- 
bility is  readily  felt  with  the  finger,  and  it  may  be  found  impossible 
to  continue  the  operation  by  this  route.  Then  the  abdomen  has  to 
be  opened  and  the  combined  operation  carried  out  with  bisection  of 
the  uterus  by  Kelly's  method.* 


Operation  for  Ovarian  Cystoma. 

For  the  operation  of  ovariotomy  for  ovarian  cystoma,  the  follow- 
ing instruments  should  be  sterilized  and  ready  to  hand  : — 
Zweifel's  and  Pean's  forceps. 
Doyen's  artery  forceps. 

*  Sea  p.  368.  If  pus  sacs  be  present,  and  hysterectomy  or  the  combined 
operation  be  deemed  inadvisable,  the  sacs  may  be  opened  and  ^e\\  mopped  out 
with  weak  formalin  dabs,  and  then  temporarily  tamponed  -with  aseptic  or 
iodoform  gauze. 


AFFECTIONS   OF   THE   OVARIES.  I'M 

Clamp  forceps,  straight  and  angular. 

Kittberle's  or  Wells'  ovariotomy  trocar. 

Wells'  smaller  trocar, 

Tait's  syphon  trocar. 

Long,  blunt  pedicle  needle. 

Deschamp's  needles. 

Sharp-curved  needles — various  sizes. 

Needleholder. 

Tenacula — single  and  double. 

Scissors — curved  and  straight. 

Some  large  flat  sterilized  sponges. 

Long  catch  forceps,  for  dabs  and  compresses. 

Various  sterilized  dressings. 

PaqueKn's  or  the  electric  cautery. 

The  clivections  already  given  for  the  preparation  of  the  instruments,  room , 
patient,  operator,  and  assistants,  so  far  as  all  aseptic  and  antiseptic  precau- 
tions are  conceraed,  hold  good  for  the  operation  of  ovariotomy.  The  various 
sutures,  ligatures,  and  dressings  used  in  cceliotomy,  and  the  toilet  of  the 
abdominal  wound,  have  been  already  described.* 

Verification  of  Number  of  Sponges,  Forceps,  etc. 

In  ovariotomy,  as  in  all  abdominal  operations  in  which  there  is  a  risk  of  a 
forceps,  dab,  sponge,  or  compress  being  left  behind,  the  forceps,  etc.,  should 
be  carefully  counted  by  one  nurse,  and  the  number  verified  and  written  down 
by  a  second  nurse. 

I  never  use  any  dab  or  sponge  in  the  abdominal  cavity  that  is  not  secured 
on  a  long,  slender,  and  light  clamp  forceps,  and  I  always  see  that  it  is  tightly 
held  before  using  it.  Each  protector  should  have  one  end  nipped  by  a  small 
pressure  forceps. 

The  Operation. — The  following  are  the  steps  of  the  operation  : — 

1.  The  abdominal  incision. 

2.  Arrest  of  haemorrhage. 

3.  Opening  the  peritoneum. 

4.  Exposure  of  the  cyst  and  management  of  adhesions. 

5.  Use  of  the  trocar  and  evacuation  of  the  cyst  contents. 

6.  Drawing  out  the  cyst  wall  and  freeing  it  of  other  adhesions, 

if  they  exist. 

7.  Arrest  of  bleeding. 

8.  Secuiing  the  pedicle. 

9.  Peritoneal  toilet. 

*  See  chapter  on  Asepsis  and  Antisepsis. 


792 


DISEASES   OF    WOMEN. 


10.  Closure  of  the  wound. 

11.  Dressing  of  the  wound. 

The  assistants  and  nurses  having  taken  their  places,  the  operator, 
standing  at  the  right  side  of  the  patient,  makes  an  incision  in  the 
usual  manner,  about  four  inches  in  length,  through  the  linea  alba. 

He  keeps  exactly  in  the  middle  line,  avoiding  the  rectus 
sheath.      If   he    should   open   this,   he   may   either    complete   the 

incision  by  cutting  di- 
rectly through  the  muscle, 
or  he  can  pass  a  grooved 
director  in  towards  the 
middle  line  to  guide  him 
in  the  linea  alba.  All 
haemorrhage  is  arrested  by 
forcipressure  or  ligature. 
The  peritoneum  is  next 
caught  by  two  Wells'  for- 
ceps, drawn  well  forward 
and  divided  between  the 
two.  If  fluid  be  in  the 
peritoneal  cavity,  the  pa- 
tient is  turned  a  little  on 
the  side,  and  the  fluid  is  allowed  to  run  through  an  extemporized 
spout  of  the  waterproof  sheeting  into  a  bucket  at  the  side  of  the 
table.  The  cyst  wall  is  thus  exposed.  With  a  trocar  of  Koeberle 
or  Wells  the  cyst  is  pierced,  and  the  fluid  permitted  to  run  through 
a  tube  into  a  side  bucket.*     The  sides  of  the  abdomen  are  pressed 


Fig.  522. — Examining  Cyst-wall  for 
Adhesions.     (Spencee  Wells.) 


Fig.  523.— Modification  of  Wells'  Trocar. 
(See  also  pjx  146,  148.) 

forwards  at  the  same  time  by  an  assistant.     The  sliding 
cannula,  or  shield,  of  the  trocar  shown  in  the  drawing, 
regulated  by  a  thumb-piece  and  bayonet-joint,  can  be 
pushed   forward   so  as  to  protect  the   point  of   the  trocar. 
*  See  p.  148  for  description  of  Eceberle's  and  other  trocars. 


The 


AFFECTIONS   OF  THE   OVARIES. 


793 


trocar  of  Tait  is  a  simple  instrument,  and  is  also  useful  for  flushing 
out  the  abdominal  or  pehdc  cavity  with  saline  solution  or  sterilized 
water  (Figs.  525,  526).  During  the  emptying  of  the  cyst,  if 
adhesions  be  exposed  they  must  be  separated  by  a  sponge  or  small 
roll  of  gauze,  held  in  a  clamp,  which  will  bo  found  most  convenient 
for  the  purpose,  and  any  bleeding  vessels  are  seized  and  quickly  tied. 


Fig.  524. — Nel.vton's  Fouceps  fok  seiztxg  Wall  of  Cyst. 

See  chapters  on  the  Operative  Treatment  of  Fibromyomata,  for  various  toothed 
forceps,  clamps,  and  other  instruments  required  in  coeliotomj'. 

Temporary  hjemostasis  is  secured  by  forcipressure.  Some  may 
be  seized  with  torsion  forceps  and  twisted.  If  the  cyst  be  multi- 
locular,  the  trocar  can  be  used  to  emj^ty  two  or  more  cysts  without 
removal  of  the  instrument,  by  plunging  it  into  each  through 
the  septum  separating  the  emptied  from  the  full  cyst.  The 
cyst  having  been  partially  emptied,  it  is  seized  with  cyst-forceps  and 
drawn  through   the  abdominal  opening,    any   remaining   adhesions 


Seven-sixteenths  of  an  inch  in  diameter. 


Figs.  525,  526. — Tait's  Syphon  Teocaks. 
Also  most  useful  in  flushing  or  syphoning  the  abdominal  cavity, 
being  freed  as  this  is  done.  The  assistant,  standing  opposite  the 
operator,  slips  his  right-hand  middle  finger  inside  the  abdominal 
wound,  including  the  entire  structures  divided,  and  he  thus  hooks 
the  abdominal  wall  forwards,  securing  both  sides  of  the  wound 
with  the  thumb  and  forefinger  of  the  same  hand.  His  left  hand 
is  thus  free  to  keep  pressure  on  either  side  if  necessary.     The  glass 


794 


DISEASES   OF   WOMEN. 


Fig.  527. — Insertion  of  Teocab  into  Cyst. 
(SpENCEK  Wells.) 


retractors  (p.  478),  are  very  useful  at  this  stage ;  the  assistant  can 
hold  the  edges  of  the  wound  well  apart  without  interfering  with 
the  operator,  or  they  can  be   made  self-retaining  with  a  band  and 

buckle  attached. 
A  large  warm  flat 
sponge  or  protector 
is  now  carefully 
slipped  in  over  the 
intestines  to  protect 
these  and  prevent 
prolapse.  In  an  or- 
dinary ovariotomy, 
when  there  are  few 
adhesions,  the  in- 
testines should  not 
be  seen  from  first 
to  last  during  the 
operation.  The  importance  of  preventing  if  possible  any  protrusion 
of  the  bowel  must  never  be  lost  sight  of.  Another  assistant  supports 
the  tumour  as  it  is  drawn  out  and  the  pedicle  cut,  and  prevents 
dragging  or  traction,  receiving  the  emptied  cyst  in  a  basin.  The 
pedicle  is  now  transfixed  with  a  long  blunt-pointed  needle,  or  one  of 
Deschamp's,  carrying  a  double  gut  ovariotomy  ligature.  This  is 
cut  and  securely  tied  in  the  manner  already  described.'"'    With  clamp 

forceps  the  pedicle 
is  now  held  below 
the  ligature,  and 
the  cyst  is  cut  ofi" 
at  a  sufficient  dis- 
tance from  the 
latter  not  to  run 
any  risk  of  inter- 
ference with  it, 
yet  leaving  enough 
of  the  pedicle  to 
enable  us  to  exa- 
mine its  surface  carefully  and  cover  it  with  peritoneum  before  it  is 
dropped  into  the   pelvic  cavity.      The  other   ovary  and    tube  are 

*  This  old  trocar  of  Wells's  is  not  now  used ;  see  pp.  146,  148,  for  Koeberle's 
and  other  trocars, 
t  See  chapter  on  Sutures  and  Ligatures." 


Fig.  528.- 


-Drawing  the  Cyst  out  op  Incision. 
(Spenceb  Wells.)  t 


AFFECTIONS   OF    THE   OVARfES. 


79r) 


thoroughly  examined  and,  if  diseased,  they  are  removed.  To  deal 
dexterously  with  adhesions,  especially  those  found  in  the  pelvis 
is  a  matter  of  experience  and  ma- 
nipulative skill.  Some  are  easily 
separated  by  the  fingers  and  small 
sponge,  held  in  a  forceps  or  holder. 
Others  require  ligaturing  and  sub- 
sequent division.  Some  may  de- 
mand division  with  the  electro- 
cautery or  Paquelin's  knife.  To  see 
adhesions  in  the  pelvic  cavity  the 
reflector  or  reflecting  mirror  is  often 
of  use. 

The  Peritoneal  Toilet.— This  is 
the  portion  of  the  operation  which 
must  not  be  conducted  hurriedly, 
and  it  is  also  the  part  requiring  most  patience  and  care.  When  the 
pedicle,  carefully  covered  over,  is  dropped  back,  the  peritoneum  is 
dried  with  dabs  or  warm  sponges,  and  all  blood  and  serum  sponged 
out.  The  abdominal  cavity  cannot  be  left  too  clear  of  any  fluid  or 
clots.  On  this  depends,  in  a  great  measure,  the  success  of  the 
operation.  If  we  have  any  serious  doubt  whether  drainage  is 
indicated,  owing  to  obstinate  haemorrhage,  prolonged  oozing,  or  the 
infection  of  the  peritoneal  cavity  by  the  escape  of  septic  material  or 
fluid  into  it,  it  is  better  to  put  in  a  glass  or  rubber  drainage-tube 
or  an  iodoform  gauze  drain  before  closing  the  wound. 


Fig.  529.— Grasping  Solid  Tka- 
BECULAR    Tumour.       (Spencer 

Wells.) 


Should  there  have  been  much  exposure  of  the  omentum  and  intestine,  or 
should  blood  in  any  quantity,  or  the  contents  of  the  cyst  or  cysts  have  escaped 
into  the  peritoneal  cavity,  the  latter  should  be  freely  irrigated  with  sterilized 
warm  saline  solution. 

Saline  Irrigation. — Tait  laid  special  stress  on  the  advantage  of  washing  out 
the  peritoneum  over  sponging.  He  used  his  syphon  trocars  (large  or  small) 
both  for  drawing  off  the  contents  of  the  cysts  and  for  syphoning  the  abdomen. 
The  indiarubber  tubing  is  attached  to  the  open  end  of  the  trocar,  and  water 
at  a  temperature  of  106°  to  107°,  or  even  to  120°  in  case  of  lu-eniorrhage,  is 
syphoned  into  the  abdomen,  Tait  used  a  special  aspirating  sucker  to  remove 
the  remains  of  the  fluid  (Fig.  530).  A  sterilized  glass  or  vulcanite  syringe 
answers  admirably. 

Hawkins  Ambler,*  writing  on  saline  irrigation  of  the  peritoneal  cavity 
during  operation,  notices  its  effects  in  the  tendency  to  cause  shock  even  under 
ansesthesia,  which  is  quickly  followed  by  a  reaction,  with  increase  in  volume 


Brit.  Gyn.  Jour.,  Feb.,  1899. 


796  DISEASES   OF   WOMEX. 

and  quality  of  the  pulse.  He  quotes  Sherrington's  experiments  of  the  effects 
on  the  blood  of  injuries  on  the  intestines  in  various  animals ;  the  blood  be- 
coming inspissated,  losing  some  of  its  plasma,  while  its  chromocj^tes  do  not 
escape  in  direct  proportion  to  the  loss  of  plasma.  This  loss  of  plasma  con- 
tinues for  a  certain  time  after,  the  specific  gravity  of  the  blood  being 
increased,  while  that  of  the  plasma  remains  unaltered.  He  believes  that 
the  exuded  plasma  to  a  gi-eat  extent  lies  free  in  the  peritoneal  cavity, 
influencing  thus  the  bacteriacidal  properties  of  the  peritoneum,  and  also 
lessening  its  absorptive  powers.  Saline  solutions  are  rapidly  absorbed 
through  the  peritoneum  into  the  circulation,  and  the  well-known  fact  of  the 
relief  of  post-operative  thirst  in  cases  in  which  irrigation  has  been  used  is  thus 
explained.  Shock  is  lessened,  the  pulse  is  improved,  and  the  tongue  remains 
moist  and  clean.     Septic  material  is  removed  with  its  culture  bacteria. 


Fig.  530. — Aspikatixg  Suckek. 

With  these  views  of  Ambler  I  quite  agree.  The  improvement  of  the  pulse 
and  countenance  after  free  saline  irrigation  in  cases  of  prolonged  operation  is 
generally  marked.  Also,  I  quite  concur  in  his  advocacy  of  mopping  out 
the  abdominal  and  pelvic  cavities  with  moist  sterilized  dabs  or  sponges  in 
septic  peritonitis  rather  than  the  use  of  any  irrigating  fluid.  The  intestines 
are  turned  out  of  the  abdomen  or  are  walled  off  by  protectors,  and  effective 
mopping  and  cleansing  is  done  with  dabs  moistened  with  very  weak  formalin 
solution  (1  in  5000). 

If  the  abdominal  cavity  be  closed  and  saline  irrigation  be  thought  desirable, 
it  can  be  carried  out  through  the  rectum.  It  has  the  effect  of  anticipating 
the  feeling  of  thirst  so  often  complained  of  after  abdominal  operations. 

The  abdominal  toilet  is  completed  in  the  manner  before  described, 
the  omentum  is  carefully .  replaced,  the  peritoneum  closed  by  fine 
silk  or  catgut,  then  the  muscle  and  fascia  with  stronger  gut,  and 
finally  the  skin  with  celloidinzwu-n,  all  three  being  continuous  sutures. 
Only  under  very  exceptional  circumstances,  which  have  been  already 
alluded  to,  is  drainage  required.  Some  prefer  silk  for  the  peritoneum, 
catgut  or  silkworm-gut  for  the  fascia,  and  silkworm-gut  for  the 
skin.     Others  use  interrupted  sutures. 


AFFECriOyS  OF   THE    OVARIES.  7'J7 

Unfavourable  Cases  and  Conditions. 

Fi-itsch  makes  some  valuable  observations  on  the  course  of  uofa- 
\  ourable  cases.  He  lays  special  stress  on  the  influence  in  laparotomy 
through  exposure  of  the  intestines,  on  the  functions  of  the  perito- 
neum through  the  contact  with  the  air,  and  the  altered  pressure, 
also  on  the  results  of  rough  and  improper  handling,  as  well  as  the 
accidental  entrance  of  cocci  from  the  intestines.  Prolonged  anaes- 
thesia, through  alteration  of  the  chemical  quality  of  the  blood,  and  the 
effects  on  the  heart  and  circulation,  tends  to  influence  the  general  and 
local  power  of  vital  resistance,  and  the  consequent  occurrence  of  sepsis. 

'  Myotomy  is  more  fatal  than  ovariotomy,  because  it  takes  longer  to  perform  ; 
and  with  every  one  the  results  become  better  as  he  learns  to  operate  better. 

'  The  course  in  unfavourable  cases  is  the  following :  The  patient  awakes 
after  the  operation  already  distressed  ;  the  breathing  is  rather  laboured  ;  the 
bandage  pressing  heavily;  otherwise  the  binding  is  well  borne.  The  cha- 
racteristic symptom  is  the  cardiac  weakness,  the  quick,  feeble  abdominal 
pulse  that  is  always  pathognomonic.  The  abdomen  is  distended,  the 
countenance  pale ;  there  is  thirst,  and  vomiting  is  frequent ;  the  tempera- 
ture is  normal ;  tympanites  increases,  and  the  pidse  becomes  worse.  These 
are  the  symptoms  of  ileus ;  but  there  is  no  ileus,  nothing  of  obstruction.  They 
are  peritonitic  symptoms ;  but  there  is  no  purulent  peritonitis.  There  is  no 
sepsis ;  there  could  be  no  sepsis  without  fever.  The  distressing  symptoms  with 
suitable  treatment  disappear.  Otherwise  on  the  third  day  or  evenmg  there  is 
some  fever,  and  this  increases  adfinem  vitae.  Care  in  not  operating  on  cases 
with  weakened  heart  or  in  which  are  condirions  of  thrombosis,  and  perfect 
technique  as  well  as  avoidance  of  loss  of  time,  are  the  important  points.' 

Ovariotomy  by  Vaginal  Coeliotomy. 

In  1898, 1  first  saw  Schauta  remove  by  vaginal  cceliotomy  a  large-sized 
ovarian  cyst.  The  anterior  incision  was  made,  the  peritoneum  opened,  and 
the  cyst  pressed  into  it.  It  was  then  tapped  and  emptied,  its  walls  seized, 
and  the  cyst  with  its  pedicle  drawn  through  into  the  vagina.  The  c^'st  was 
then  removed  after  hgature  of  its  pedicle,  which  was  returned ;  the  peritoneum 
and  vaginal  wall  were  then  carefully  sutured.  Schauta  has  also  operated  in 
this  manner  on  multUocular  cysts  by  emptying  successively  the  cavities,  also 
on  broad  ligament  cysts,  hgaturing  the  large  vessels,  emptying  the  cyst,  and 
shelling  it  out.  In  cases  where  the  peritoneum  has  become  soiled  by  cyst 
contents,  as  in  the  case  of  dermoids,  an  iodoform  drain  is  used.  He  limits 
this  method  of  ovariotomy  by  the  A-aginal  route  to  movable  cysts  vjithout 
adhesions,  and  those  which  are  not  intra-ligamentary.  The  greatest  care  is 
necessary  in  diagnosis.  Taking  into  consideration  the  risks  of  complications 
which  coidd  not  have  been  foreseen ;  the  deceptive  nature  of  some  appa- 
rently unilocular  cysts;  the  difficulty  of  delivery  of  the  cyst  or  cysts  in 
consequence,  the  possible  failure  in  its  delivery  by  the  vagina,  there  can  be 
no  question  that  the  abdominal  route,  in  the  great  majority  of  cases,  is  the 
safer  and  most  simple  for  the  surgeon  to  adopt. 


CHAPTER   XLII. 


AFFECTIONS    OF   THE   VULVA. 


Atresia 

Hermaphroditism . 

Hypertrophy  of  the  nymphae  and 
clitoris. 

Hypersesthesia  (generally  asso- 
ciated with  vaginismus). 

Erythema. 

Erysipelas. 

Eczema. 

Herpes. 

Pediculi. 

Pruritus. 

Lichen  (extremely  rare). 

Lupus. 

Tuberculosis. 

Oozing  papilloma. 

Rodent  ulcer. 

Epithelioma. 

Medullary  cancer. 

Melanosis. 

Elephantiasis. 

Syphilis : 

Primary 

Secondary  syphilides. 

Condylomata. 


Vulvitis  : 

Simple. 

Purulent. 

Phlegmonoid. 

Specific. 

Eollicular. 
Phlegmonoid  inflammation  of  the 

labia  majora. 
Abscess. 

Gangrene  (noma). 
Vegetations. 
Cysts. 
Varix. 
Hgematoma. 
Pudendal  haemorrhage. 
Tumours  : 

Elephantiasis. 

Neuroma. 

Sebaceous. 

Fibromyoma. 

Lipomas. 

Sarcoma. 

Cystic. 
Hernia  (of  ovary). 
Hernia  (of  intestine). 
Hydrocele. 


These  are  all  the  more  important  affections  of  the  vulva.  I  shall 
deal  briefly  with  those  that  most  commonly  come  under  the  observa- 
tion of  the  gynaecologist. 

Atresia  of  the  Vulva,  Congenital  or  Acquired. — Congenital  mal- 
formation  of   the   vulva   may    accompany  hypospadias  and  other 


AFFECTIONS   OF  THE    VULVA.  799 

anomalies  of  the  genital  organs.  The  vulva  may  (very  rarely)  be 
entirely  absent,  or  permanently  retain  its  infantile  form.  The  laljia 
majora  or  the  nymphsB  may  be  adherent,  and,  occasionally,  the 
former  are  so  united  posteriorly  as  to  present  the  a})pearance  of  an 
enlarged  perineum.  The  vulvar  orifice  is  sometimes  closed  from  the 
same  causes  that  produce  atresia  of  the  vagina. 

Malformations — Hermaphrodism, 

In  regard  to  various  malformations  seen  in  the  adult  female, 
some  developmental  processes  in  the  foetus  are  w^orthy  of  notice. 
Arrest  of  development  of  the  genital  tubercle,  or  its  division,  is 
associated  with  absence  of  the  vulva  or  atresia  of  the  vagina,  while 
other  deviations  in  the  completion  of  the  urethra,  vagina,  and  anus, 
through  the  partitioning  of  the  foetal  cloaca,  lead  to  the  various 
abnormalities  found  in  the  vulva,  urethral  orifice,  and  clitoris, 
resulting  either  in  hypertrophy  of  the  lips  or  closure  of  the  orifices, 
both  of  the  vulva  and  urethral  meatus.  In  other  cases,  owing  to 
similar  arrest  of  development,  the  bladder,  vagina,  and  rectum 
may  open  into  a  cloaca  common  to  all  three,  or  hypospadias  may  be 
the  consequence. 

In  one  form,  while  the  clitoris  is  hypertrophied  there  is  a  long 
vestibular  canal  into  which  the  vagina  opens ;  in  the  other,  the 
allantois  is  entirely  converted  into  the  bladder,  the  urethra  is  absent, 
and  the  former  viscus  opens  directly  into  the  A'estibule.  Here  the 
perineal  body  is  present. 

Hermaphroditism. — Neugebaur  adopts  Klebs  classification  : — * 

Pseudo-hermaphrodism  :  (1)  Masculine  (androgynoid)  occurring  in 
the  male ;  (2)  Feminine  (gynandroid)  in  the  female. 

And  of  each  of  these  theie  are  three  varieties :  (a)  Internal ; 
(6)  External ;  (c)  Complete. 

I.  Feminine  Pseudo-hermaphrodisni. — Varieties :  (cf)  Internal :  External 
genital  organs  feminine  ;  sijuultaneotis  development  of  the  duds  (if'  Wolff  aiid 
those  of  Mutter,  but  to  different  degrees.  (&)  External:  External  genital 
organs  apparently  masculine ;  adherent  labia  majora  resembling  a  scrotum, 
hypertrophied  clitoris  resembling  a  penis  with  hyposjmdias,  viz.  perforated 
by  the  urethra,  and  like  a  normal  penis ;  Ectopia  of  the  ovaries  in  the  labia 
simulating  testicles  in  a  scrotum  ;  internal  genital  organs  feminine,  (c)  Com- 
plete :  External  genital  organs  approaching  the  masculine  type,  internal  genital 

*  For  this  summary  of  certiun  cmbryological  processes  relating  to  the  occur- 
rence of  hermaphrodism,  I  am  mainly  indebted  to  Neugebaur  and  the  article  in 
'  Quain's  Anatomy.'  8ee  contribution  on  '  Hermaphrodism  in  the  Daily  Practice 
of  Medicine,'  by  Dr.  ]Med  Franz  von  Xcugebaur.  liril.  Gyn.  Jour.,  1903. 


800  DISEASES   OF    WOMEN. 

organs  feminine,  more  or  less  developed,  with  simultaneous  development  of 
Wolffian  ducts  to  a  certain  degree. 

II.  Masculine  Hermaphrodism. — Varieties  :  (a)  Internal :  External  genital 
organs  masculine,  with  masculine  internal  sexual  organs ;  more  or  less 
development  of  Miiller's  ducts  (uterus,  oviducts,  vagina,  broad  and  round 
ligaments).  (&)  External :  External  genital  organs  feminine  in  appearance, 
in  consequence  of  penoscrotal  hypospadias,  with  or  without  cryptorchism  ; 
internal  genital  organs  masculine,  (c)  Complete :  External  genital  organs 
feminine  in  appearance ;  infernal  genital  organs  masculine,  more  or  less 
developed,  with  simultaneous  development  of  Miiller's  ducts. 

Simulation. — Penoscrotal  hypospadias  with  cryptorchism  and  the  develop- 
ment of  a  more  or  less  rudimentary  vagina  simulates  the  presence  of  a  vulva  ; 
hypertrophy  of  the  clitoris  simulates  hypospadias  of  a  penis ;  labial  ectopia  of 
the  ovaries,  the  testicles ;  adherence^  of  the  labia  majora,  the  scrotum ;  non- 
adherent labia,  a  divided  scrotum. 

A  description  of  various  forms  of  pseudo-hermaphrodism  is 
rendered  clearer  by  a  classification  of  the  reproductive  organs 
according  to  the  embryological  structures  from  which  they  are 
developed,  as  follows  : — ■ 

{a)  Glandular,  derived  from  the  germinal  ridge,  and  consisting  of 
the  testis  in  the  male,  and  the  ovary  in  the  female. 

{b)  Intermediate,  situated  between  the  glandular  and  the  ex- 
ternal organs,  and  derived  from  the  Wolffian  duct  and  body  in  the 
male,  and  from  the  Miillerian  duct  in  the  female. 

(c)  External,  which  are  developed  from  the  uro-genital  sinus. 

The  nature  of  the  glandular  organs  exclusively  determines  the 
sex  of  the  individual.  The  possessor  of  testes  is  male,  and  of 
ovaries  female,  irrespective  of  the  nature  of  the  intermediate  or 
external  organs.  True  hermaphrodism  would  therefore  imply  the 
presence,  in  the  same  individual,  of  testes  and  ovaries,  or  of  a 
testicle  on  one  side,  and  an  ovary  on  the  other. 

Neugebaur  assumes  that  theoretically  we  must  admit  the  possi- 
bility of  the  foetus  with  two  testicles  and  two  ovaries,  or  two 
testicles  and  one  ovary,  or  one  testicle  and  ovary,  in  which  case  we 
should  have  true  hermaphrodism.  Yet  not  one  single  case  has 
been  put  forward  which  has  stood  the  test  of  critical  microscopical 
examination,  nor  has  any  instance  ever  been  recorded  of  the  same 
individual  having  been  capable  of  coition  as  a  male  and  having 
become  pregnant. 

In  a  few  instances,  however,  testicular  and  ovarian  tissues  have 
been  detected  microscopically  in  the  same  genital  gland,  which, 
therefore,  constituted  an  ovo-testis.  At  other  times  the  microscope 
fails  to  assist  in  revealing  the  sex,  the  glands  being  so  ill-developed, 


AFFECTIOXS   OF   THE    IT/,  1.1.  S(il 


that,  on  histological  examination,  nothing  but  fibrous  tissue  and 
bloodvessels  arc  discovered ;  but  abnormal  histological  features  are 
not  generally  of  such  practical  importance  in  a  case  of  pseudo- 
herinaphrodism  as  the  possibility  of  an  ill-developed  testicle  resem- 
bling an  ovary  on  palpation,  or  of  the  gland  in  question  occupying 
an  anomalous  position.  Both  ovaries  and  testicles  are  originally 
situated  at  a  distance  from  the  site  which  they  are  destined  to 
occupy  in  the  adult,  and  in  its  descent  an  ovary  may  follow  the 
course  normally  taken  by  the  testicle,  and  occupy  the  inguinal 
canal — a  rare  condition, — or  pass  on  into  the  labium  majus,  while 
a  testicle  may  be  arrested  in  or  before  it  reaches  the  canal. 

Intermediate  Organs. — At  an  early  stage  of  development,  on 
each  side  of  the  middle  line,  there  are  two  tubes,  the  Wolffian  and 
Miillerian  ducts,  which  run  from  before  backwards  in  close  apposi- 
tion for  the  greater  part  of  their  course.  Each  Wi3lffian  duct  in 
the  male  becomes  the  tube  of  the  epididymis,  vas  deferens  and 
ejaculatory  duct  on  the  same  side.  In  the  female  it  atrophies. 
The  Miillerian  ducts  coalesce  at  the  posterior  ends.  The  single 
tube  resulting,  develops  in  the  female  into  the  uterus  and  vagina, 
while  the  fr-ee  ends  become  the  Fallopian  tabes.  In  the  male, 
atrophy  of  these  duets  takes  place.  Thus  in  either  sex  the  more 
readily  detectable  internal  organs  peculiar  to  it  are  developed  from 
a  pair  of  ducts  which  in  the  other  sex  atrophies,  though  they  never 
wholly  disapjDear,  the  vestigial  remains  being  present  even  in  the 
adult.  The  two  sets  of  ducts  occasionally  undergo  simultaneous 
though  unequal  development,  and,  as  a  consequence,  heterologous 
internal  sexual  organs  are  present.  Such  a  condition  is  one  of 
internal  pseudo-hermaphrodism.  The  partial  or  complete  develop- 
ment of  these  heterologous  organs,  e.g.  the  vagina  and  uterus  in  the 
male,  is  frequently  associated  with  deficient  development  of  those 
which  are  naturally  present.  The  structures  derived  from  the 
Wolffian  body  are  not,  in  this  particular  connection,  of  sufficient 
practical  importance  to  call  for  special  notice. 

External  Organs. — At  the  end  of  the  third  month  of  foetal  life 
the  urogenital  aperture  in  both  se.xes  consists  of  a  narrow  opening 
continued  forwards  as  a  furrow  (urogenital  furrow)  into  an  integu- 
mentary projection,  the  sexual  eminence,  situated  in  front  of  it,  and 
itself  encircled  by  a  deep  fold  of  integument.  The  genital  eminence 
constitutes  the  rudiment  of  the  penis  and  clitoris.  In  the  male  it 
enlarges  to  form  the  penis,  and  the  lips  of  the  gi'oove  on  its  under 
surface  unite,  thus  forming  the  greater  portion  of  the  male  urethra. 

3    F 


802  DISEASES   OF   WOMEN. 


In  the  female  the  eminence  remains  small,  the  groove  on  its  under 
surface  becomes  shallow,  while  its  lips  do  not  unite,  but  extend 
backwai-ds,  and  become  elongated,  to  form  the  nymphs.  The  lips 
of  the  deep  fold  of  integument  encircling  the  sexual  eminence 
become  the  labia  majora  and  mons  veneris  in  the  female,  but  unite 
in  the  male  as  the  scrotum.  Lastly,  the  erectile  tissue,  which 
occupies  the  lateral  wall  of  the  urogenital  sinus,  foi*ms  the  bulbi 
vestibuli  in  the  female,  but  becomes  united  in  the  male  in  the 
corpus  spongiosum. 

Thus  the  external  genital  organs,  unlike  the  intermediate,  are 
derived  from  the  same  structures  in  both  sexes,  and  the  co-existence 
of  those  peculiar  to  the  male  and  female  is  impossible.  The  clitoris 
may,  however,  be  so  developed  as  to  resemble  a  penis  closely,  and, 
in  the  female,  union  may  take  place  between  any  of  the  structures 
on  either  side,  which  normally  unite  in  the  male,  giving  rise  to 
almost  every  variety  of  external  genitals  intermediate  between 
those  typical  of  either  sex.  More  frequently  a  reverse  process  in 
the  male  gives  rise  to  intermediate  forms,  and  typical  female 
genitals  may  be  present. 

External  pseudo-hermaphrodism  implies  the  presence  in  the 
male  or  female  of  one  of  these  anomalous  conditions ;  and  complete 
pseudo-hermaphrodism,  that  there  is  hermaphrodism  of  the  internal 
as  well  as  the  external  organs. 

Nengebaur  regards  the  piincipal  role  in  the  etiology  of  hermaphrodism 
during  the  developmental  process  as  taken  by  the  anatomical  disposition  of 
the  arteries,  involving  the  supply  of  blood  to  the  genital  organs,  which  he 
divides  into  three  sets  in  the  male  and  female,  each  set  having  its  own  special 
circulation,  on  the  integrity  of  which  its  development  may  be  either  normal 
or  retarded. 

PsycMc  Influences. — There  appears  to  be  sufficient  evidence  to  prove  that 
the  factor  of  heredity  must  be  taken  into  consideration  in  the  etiology  of  the 
malformation,  several  instances  having- been  recorded  in  which  atavism  could 
be  distinctly  traced  as  a  predisposing  factor,  possibly  through  a  psychic 
influence  on  the  part  of  the  mother. 

Secondary  Sexual  Characteristics. — By  these  are  meant  the 
distinctive  traits  which  appear  in  either  sex  at  puberty,  and  include 
the  general  configuration  and  development,  the  appearance  of  the 
mammae,  the  disposition  of  the  subcutaneous  adipose  tissue  and  its 
amount,  the  development  and  disposition  of  hair  on  the  face  and 
body  ;  the  shape  and  size  of  the  larynx,  and  the  pitch  of  the  voice ; 
and  the  sexual  desires.  Any  of  these  characteristics  may  be 
appropiate  to  the  sex,  or  homologous  with  the  sexual  glands,  and, 


AFFECTION!^    OF    THE    ViriVA. 


sns 


on  the  other  hand,  they  may  be  those  of  the  opposite  sex  or 
heterologous. 

Diagnosis. — Before  puberty,  if  the  question  of  sex  arises,  it  is 
owing  to  the  presence  of  abnormal  external  genitals.  If  the  testes 
and  their  adnexa  can  be  detected,  or  a  fairly  developed  uterus  and 
vagina  is  present,  an  opinion  may  be  expressed,  with  certainty  in 
the  former  case.  Under  other  circumstances  it  is  wiser  not  to 
hazard  an  opinion,  but  to  await  puberty,  when  the  sex  will  probably 
declare  itself. 

In  a  newly  born  infant  an  internal  examination  is  not  possible. 


7////  — 

Pl 

7J0 

I 

— /■- ; 

4 

V 

Ay  — 

v_ 

-— t-'; 

.'«• 

\ 

V.^- 

'/.... 


Fig.  531. — Pseudo  -  hermaphuo- 
msM,  WITH  Perixeo-sckotal 
Hypospadias. 

g,  glans;  mu,  meatus  urin. ;  pl, 
lab.  min. ;  vo,  vulvar  orifice; 
liy,  hymen  :  /,  fourchette. 


V^^^V 


r 


Fig.    532.- — PsEuro-iiEiiiiAriiKODisji,  with 
Perixeo-scrotal  Hypospadias.  (Zweifel.) 

B,  bladder  ;  T,  testicle ;  P',  symphysis  ; 
P,  penis  (hyposijadic);  pv,  prostatic  ve- 
sicle and  pseudo-vagina ;  K,  rectum. 
(Pozzi.) 


After  puberty  the  question  is  raised  by  the  appearance,  or  non- 
appearance, of  menstruation,  or  because  of  seminal  emissions  in  a 
supposed  female ;  or,  on  account  of  dyspareunia,  sterility,  deformity, 
or  the  general  appearance  of  the  individual.  In  such  a  case  rectal 
or  A^aginal  examination  may  disclose  the  presence  of  a  prostate  or 
uterus ;  but  the  diagnosis  depends  ultimately  upon  the  detection  of 
the  testes  or  ovaries,  or  of  semen  or  menstruation.  In  a  few  in- 
stances the  prostate  gland  has  been  found  in  the  female,  and 
periodic  genital  haemorrhages  have  been  recorded  as  occurring  in 
male  pseudo  hermaphrodites. 


804  DISEASES   OF   WOMEN. 

Bearing  Ckn  this,  the  following  case  of  Martin  is  of  interest : — 

Testicles  in  Inguinal  Canal  of  Hermaplirodite. — Christopher  Martin  (Bir- 
mingham) removed  a  testicle  from  the  inguinal  canal  of  a  pseudo-hermaphro- 
dite. The  patient  was  twenty  years  of  age,  had  been  brought  up  as  a  girl,  and 
earned  her  living  as  a  nurse.  She  had  never  menstruated.  She  had  been 
operated  on  by  another  surgeon  for  a  r-ight  inguinal  hernia,  radical  cure  being 
performed.  At  this  operation  a  solid  oval  body,  supposed  to  be  an  ovary, 
was  found  in  the  sac,  and  returned  into  the  peritoneal  cavity.  Later  on  an 
inguinal  swelling  had  formed  on  the  left  side.  Neither  her  features  nor  her 
voice  were  masculine.  There  was  no  development  of  beard  or  moustache. 
The  breasts  were  flat  and  poorly  developed.  The  figure  was  slim,  but  more 
suggestive  of  the  female  than  the  male  sex.  There  was  a  distinct  mons 
veneris,  but  an  entire  absence  of  hair  on  the  genitals.  The  scar  of  the  previous 
operation  was  visible  on  the  right  side,  but  there  was  no  hernial  protrusion. 
In  the  left  inguinal  region  was  a  small  oval  swelHng,  tender  to  the  touch,  and 
producing  a  sickening  sensation  on  pressure.  It  was  solid,  could  not  be 
reduced  into  the  abdomen,  and  was  situated  immediately  over  the  external 
abdominal  ring.  There  was  no  impulse  on  coughing.  The  external  genitals 
exactly  resembled  those  of  a  nulliparous  female.  The  labia  majora  and 
minora  were  normally  developed.  The  clitoris  was  of  the  natural  size  ;  it  was 
not  grooved,  and  did  not  resemble  a  penis.  On  separating  the  labia  the 
urethra  was  seen  opening  in  the  middle  of  a  normal  female  vestibule.  The 
vagina,  however,  was  only  represented  by  a  short  blind  cul-de-sac,  three- 
quarters  of  an  inch  deep,  admitting  only  the  first  joint  of  the  forefinger.  No 
trace  of  a  cervix  or  uterus  could  be  felt.  The  urethral  canal  was  about  one 
and  a  half  inches  long,  and  was  not  surrounded  by  anything  resembling  a 
prostate.  On  introducing  a  sound  into  the  bladder,  and  the  forefinger  into  the 
rectum,  no  solid  body  like  a  uterus  could  be  discovered  intervening. 

At  operation  a  serous  sac  was  laid  open  enclosing  an  oval  solid  body 
about  one  inch  long.  This,  on  closer  examination,  proved  to  be  a  testicle, 
and  the  sac  the  tunica  vaginalis  testis.  The  gubernaculum  testis  was  well 
marked,  and  passed  into  the  tissues  of  the  left  labium  majus.  The  testicle  was 
freed  from  its  surroundings,  the  cord  isolated,  ligatured,  and  divided,  and  the 
organ  removed.  The  peritoneal  cavity  was  opened  at  the  upper  end  of  the 
ino-uinal  canal,  the  forefinger  introduced,  and  the  pelvis  explored.  No  trace  of 
a  uterus  could  be  felt,  but  the  vas  deferens  could  be  made  out — when  the  cord 
was  dragged  on — as  a  tense  band  coursing  backwards,  downwards,  and 
inwards  by  the  side  of  the  bladder.  The  gland  on  the  other  side  could  not 
be  felt. 

The  removed  organ  had  a  well-marked  tunica  vaginalis  testis.  .  The 
epididymis  arched  around  the  posterior  border  of  the  gland,  and  the  globus 
major,  the  globus  ujinor,  and  the  digital  fossa  were  normally  developed. 

On  section,  the  secreting  tissue  was  enveloped  in  a  tunica  albuginea.  Pro- 
fessor Allan  made  a  series  of  microscopic  sections  of  the  gland,  which  proved 
it  unmistakably''  to  be  a  testicle.  The  seminal  tubules  were  shown  in  various 
stages  of  development,  and  in  a  few  tubules  imperfect  spermatozoa  were  dis- 
tinguished. 

Martin,  nine  months  subsequently,  removed  from  the  right  groin  of  the  same 


AFFECTIONS  OF  THE    VULVA.  805 


patient  what  proved  to  be  the  right  testis.  There  was  an  excellent  recover}'. 
After  tlie  first  testis  was  removed,  hair  began  to  grow  on  the  pubes,  and 
symptoms  of  hysteria  developed.  When  the  second  was  taken  away,  the 
breasts  became  swollen  and  tender,  and  more  fully  developed.  At  the  same 
time  '  heats  and  flushes '  were  complained  of,  which  recalled  those  of  the 
menopause.  Microscopic  sections  of  this  testis  were  also  made  by  Professor 
Allan.     Martin  concluded  that  in  this  case  the  true  sex  was  luascaliae. 

It  is  extremely  interesting  to  note  that  the  patient's  sister — two  years  her 
elder — has  never  menstruated,  has  infantile  breasts,  no  pubic  hair,  only  a 
shoit  cul-de-sac,  one  inch  long,  for  a  vagina,  and  no  signs  of  a  uterus.  At  the 
time  of  the  conception  of  both  children  the  father  was  insane. 

Neugebaur  has  collected  statisiics  from  930  cases  of  pseudo-hermaphro- 
dism,  33  of  which  came  under  his  personal  observation.  The  particulars  of 
many  of  these  cases  prove  the  great  obscurity  in  v/hich  the  sex  of  the  person 
must  be  involved  until  accidental  circumstances  hajipen  to  lead  to  its  dis- 
covery. It  is,  indeed,  a  question  whether  there  may  not  have  been  cases 
which  never  have  been  detected.  They  aho  prove  the  difficulty  there  may 
be  in  some  cases  in  making  a  diagnosis.  The  bare  mention  of  two  instances 
is  sufficient. 

Neugebaur  relates  as  the  most  extraordinary  the  case  of  Charles  Menniken, 
who  had  led  a  married  life  from  the  age  of  27  to  that  of  57,  dying  of  cancer. 
A  necropsy  was  performed,  which  proved  that  for  these  thirty  years  tlie 
female  pseudo-hermaphrodite  had  co-habited  as  a  man. 

In  tiie  celebrated  case  of  Catherina  Hohraann  (regarded  by  Rokitauski  as 
veritable  hermaphrodism),  there  was  regular  menstruation,  and  there  were 
feminine  characteristics.  She  cohabited  as  a  woman  for  twenty  years,  and 
then  maiTied  as  a  man. 

Case  of  pseudo-hermaphroditism,  in  which  there  was  a  divided  scrotum  with 
masculine  uterus  and  patent  utero-genital  canal. 

Arthur  Maude  has  recorded  an  interesting  case ;  *  the  father  of  the 
hermaphrodite  had  been  insane,  and  another  child  had  died  of  tubercular 
meningitis.  The  general  conformation  of  the  subject  was  masculine ;  the 
hair  of  the  head  was  comparatively  short ;  there  was  none  on  the  face.  The 
age  was  thirteen  and  a  half  years. 

'  The  genitals  showed  no  mons  veneris ;  there  was  a  penis  about  one  and  a 
quarter  inch  long,  rather  small  for  a  boy  of  the  age.  The  glans  was  well 
formed,  there  was  no  prepuce ;  the  relative  arrangement  of  the  corpora 
cavernosa  and  spongiosum  were  normal.  The  urethra  perforated  the  corpus 
spongiosum  and  glans,  and  there  was  no  hypospadias.  The  penis  was  con- 
nected by  a  sickle-shaped  fold  or  frtenum  of  the  skin  in  the  middle  line  of  the 
posterior  surface,  so  as  to  be  slightly  curved.  This  frsenum  extended  from 
the  frsenum  prseputii  to  the  root  of  the  penis. 

'  From  the  root  of  the  penis  sprang  a  divided  scrotum,  the  halves  of  which 
were  shut  off  into  two  complete  sacs  connected  by  an  arciform  web  of  skin 
which  Happed  a  short  way  over  the  genital  cleft.  This  consisted  of  a  small 
vagina,  admitting  the  forefinger  for  an  inch. 

"^  Neugebaur  pronounces  this  case  of  3Iaude's  as  almost  unique. 


806  DISEASES   OF    WOMEN. 


'  There  were  no  labia  majora,  and  no  proper  labia  minora,  but  there  was  a 
sort  of  radimentary  flat  space  like  the  vestibule  in  front  of  the  vagina  and  also 
behind. 

'  No  uterus  could  be  felt  bj'  bimanual  examination. 

'  The  divided  scrotum  contained  a  gland  in  each  half ;  the  one  on  the  right 


L'a:;!-:  of  rsEUDij-H^UMAi'HuoniTisM.     (Akthuu  Maude.) 


side  was  somewhat  larger  than  that  on  the  left;  both  were  about  as  large  as 
testicles  usually  are  in  a  well-grown  boy  of  ten  or  twelve. 

'Both  glands  presented  the  shape  of  testicles  and  had  an  epididymis  behind 
each. 

'  There  had  never  been  any  menstrual  flow. 

'  The  question  of  sexual  appetite  was  not  entered  into.' 

Psychical  Effects. — The  psychical  eflfects  of  hermaphrodism  have 
to  be  remembered.  Crime  is  not  uncommon,  and  the  suicidal 
tendency  has  been  frequently  present.  On  the  other  hand,  pseudo- 
hermaphrodites have  been  themselves  the  victims  to  crime,  the 
consequences  of  the  discovery  of  their  malformation  on  the  part  of 
those  who  had  had  relationships  with  them. 

There  is  an  error  which,  for  completeness,  should  be  mentioned. 
It  has  many  times  happened  that  a  testicle  in  the  inguinal  canal  of 
a  supposed  girl  has  been  diagnosed  and  treated  as  an  inguinal 
hernia, 

Neugebaur,    in    28    instances   of   this   malformation,    discovered 


AFFECTtOSS   OF   THE    VULVA.  807 

various  benign  or  malignant  new  growths  in  the  genitalia,  bladder? 
or  rectum. 

Treatment. — As  to  the  course  which  should  be  adopted,  when 
the  SL'x  is  doubtful,  in  bringing  up  the  child,  it  is  generally 
accepted  as  correct  to  treat  the  child  as  a  boy,  inasmuch  as  in 
the  great  majority  of  cases  it  is  a  male.  Lawson  Tait  recom- 
mended that  it  should  be  treated  as  a  girl,  under  which  cir- 
cumstances it  would  be  subjected  to  much  less  unpleasantness  on 
account  of  its  deformity.  There  are  two  conditions  in  which  opera- 
tive procedures  are  usually  advisable  :  in  the  female,  when  connection 
is  impossible  and  may  be  rendered  possible  ;  and  when  it  is  possible 
to  restore  the  penis  and  scrotum  of  a  penoscrotal  hypospadiac,  so  as 
to  enable  him  to  micturate  in  the  usual  manner,  a  point  emphasized 
by  Neugebaur,  and  to  facilitate  connection.  In  a  few  instances  a 
diagnostic  operation  has  been  performed. 

The   Clitoris. 

The  clitoris  has  been  attacked  by  elephantiasis,  fibroma,  sarcoma, 
carcinoma,  and  cystic  degeneration.  It  may  be  congenitally  de- 
formed or  overlapped  and  concealed.  The  glands  may  be  adherent 
to  the  prepuce,  and  occasionally  is  the  seat  of  a  concretion  ;  or  the 
prepuce  may  be  enlarged,  and  the  entire  organ  hypertrophied. 

Kelly  insists  on  the  necessity  for  examining  the  clitoris  in  all 
cases  where  there  is  any  tendency  to  handle  or  rub  the  genitals, 
especially  in  children.  In  Fig.  534,  in  which  there  was  congenital 
malformation  of  the  vulva  and  partial  atresia  of  the  vagina,  the 
small,  partially  covered  clitoris  is  seen. 

Absence  of  the  Internal  Genitalia — Formation  of  a  Vagina. — 
A  child  of  three  years  of  age  was  brought  to  me  for  atresia  of 
the  vagina.  The  state  of  the  parts  is  shown  in  Fig.  534.  The 
entrance  to  the  vagina  was  completely  closed.  A  small  orifice  led 
to  a  normal  urethra.  The  outlet  was  closed  completely  by  integu- 
ment. On  incising  this,  to  a  depth  of  about  a  quarter  of  an  inch, 
I  came  on  a  rudimentary  A'aginal  canal,  which  was  large  enough  to 
admit  the  little  finger,  and  at  its  upper  end  was  a  small  nodule 
which  represented  the  cervix  uteri.  Examining  through  the  rectum 
for  the  uterus,  bimanually,  and  with  a  dilator  in  the  bladder,  I 
could  feel  an  imperfectly  developed  uterus,  about  three-quarters  of 
an  inch  in  length  and  a  centimetre  in  width,  but  there  was  no 
vestige  of    adnexa    at    either    side.     This  was  verified    by  a  most 


808  DISEASES   OF    WOMEN. 


carafal  examiaatioa.     1  enlarged  the  vaginal  opening  by  a  backward 
incision,  aiid  freed  the  lower  portion  of  the  mucous  membrane  of 


Fig.  534. — Congenital  Malformation  of  the  Vulva,  Partial  Atresia  of 
THE  Vagina  "with  Abnormal  Uterus,  and  Absence  op  the  Ovaries  and 
Tubes  in  a  Child  of  Three  Years  of  Age.     (Author.) 

the  small  vaginal  canal,  bringing  it  down  and  fixing  it  at  the 
outlet.     The  cosmetic  effect  was  all  that  could  be  desired. 

Carcinoma  of  the  Clitoris. — B.  J.  Orkqvist,*  from  an  analysis  of 
sixty-seven  cases  of  carcinoma  of  the  clitoris,  rejects  the  view  that 
masturbation  is  as  common  a  cause  of  carcinoma  of  the  clitoris 
as  has  been  supposed,  inasmuch  as  70  per  cent,  of  the  cases  have 
been  over  fifty  years  of  age.  Syphilis  is  a  more  likely  cause,  though 
irritation,  the  result  of  pruritus,  may  also  have  predisposing  effects. 
Medullary  carcinoma  is  extremely  rare,  only  one  case  having  been 
reported.  Scirrhus  is  also  rare,  the  growth  being  generally  a 
squamous  cell  carcinoma. 

Charles  Noble  has  recorded  a  case  of  epithelioma  of  the  clitoris. 
The  tumour  was  half  an  inch  in  breadth,  depth,  and  thickness, 
with  prolongations  into  the  right  labium  majus,  while  the  skin  of 
both  labia  was  unhealthy  and  oedematous,  having  a  macerated 
surface,  which  was  nodular  and  covered  with  thickened  and  whitish 
epithelium.  There  was  no  enlargement  of  the  inguinal  glands.  He 
removed  a  portion  of  the  mons  veneris,  the  upper  portions  of  both 
labia  majora,  the  vestibule,  with  the  subcutaneous  fat  and  fascia, 

*  FesUclirift.  gwidmet  Engstrom,  Berlin,  1903. 


AFFUCTJO.XS  or  TllK    vrr.VA. 


81  lit 


and  some  lymphatics  from  each  groiQ.     The  inguinal  glands  were 
not  involved.* 


Fig.  535. — Epithelioma  op  the  Clitoris.    (C.  Noble.) 

Fibroma  of  the  Clitoris. — A  patient  came  to  me  for  severe  vaginismus  and 
diiSculty  in  coitus.  On  examination  I  discovered  springing  from  a  hyper- 
trophied  clitoris  a  pear-shaped,  fibromatous  mass,  which  the  patient  stated 
had  been  there  for  years,  but  had  of  late  grown  larger.  I  removed  this  with 
the  galvanic  ecraseur,  and  with  subsequent  dilatation  she  was  rapidly  cured. 
It  was  a  pure  fibroma. 


Cutaneous  Affections. 

It  is  not  possible  in  a  work  of  this  nature  to  attempt  more  than 
a  brief  description  of  some  of  the  more  commonly  occurring 
cutaneous  affections  of  the  vulva.  Cutaneous  diseases  attacking 
this  part  must  be  regarded  as  much  within  the  province  of  the 
gynaecologist  as  the  dermatologist.  Local  peculiarities  being  remem- 
bered, they  must  be  treated  on  general  principles  and  by  the  local 
measures  we  adopt  for  dealing  v/ith  similar  skin  affections  elsewhere. 

In  the  external  srenitalia  we  have  to  treat  cutaneous  affections  of 


Amer.  Jour.  Ohstet.,  and  '  Diseases  of  Women  and  Children,'  vol.  slvi.,  No.  2, 


1902. 


810  DISEASES   OF   WOMEN. 


which  the.  clinical  characteristics  are  materially  influenced  by  the 
local  anatomical  and  physiological  peculiarities  of  this  part. 
Certain  general  principles  must  be  observed. 

1.  Attention  to  any  predisposing  constitutional  condition,  as,  for  example, 
hj'steria,  gout,  struma,  diabetes,  or  scorbutic  tendency.  Disorders  of  the 
urinarj^  organs — cystitis,  phosphates  and  uric  acid  in  the  urine — predispose 
to  vulvar  inflammation,  as  they  do  to  vaginitis  (see  Vaginitis).  A  history  of 
syphilis  must  be  inquired  into  if  the  appearances  indicate  any  specific  taint. 

2.  Scrupulous  cleanliness.  Medicated  baths,  as  those  of  starch  and  soda, 
should  be  used,  after  Avhich  special  lotions  or  unguents  ma}''  be  applied. 

3.  Any  uterine,  vaginal,  or  urethral  affection,  which,  by  an  irritating  dis- 
charge or  otherwise,  may  cause  or  aggravate  the  skin  affection  should  be  cured. 

Hypersesthesia. — Glaillard  Thomas  has  drawn  special  attention  to 
this  painful  condition.  We  constantly  see  patients  in  whom  we 
cannot  detect  the  least  abrasion,  vegetation,  or  irritable  caruncle, 
and  yet  the  introduction  of  the  finger  between  the  labia  causes 
exquisite  pain.  Hypersesthesia  may  attend  on  irritable  urethral 
caruncle,  painful  vegetations,  or  the  red  patches  described  by 
Lawson  Tait,  and  is  occasionally  met  with  where  we  have  other 
manifestations  of  hysteria.  It  is  the  morbid  condition  most  fre- 
quently associated  with  vaginismus.  The  treatment  first  outlined  by 
Gaillard  Thomas  is  that  which  I  have  found  of  the  greatest  service. 
This  consists  in  :  1 .  Attention  to  the  general  health  by  restoratives 
and  tonics.  2.  The  application  of  local  sedatives  and  astringents, 
such  as  belladonna,  opium,  or  chloroform ;  painting  the  dry  part 
with  cocaine  solution  (10  per  cent.)  ;  bismuth,  iodoform,  tannin, 
oxide  of  zinc,  ichthyol,  in  the  form  of  ointment ;  brushing  the 
surface  with  weak  nitrate  of  silver  solution.'"'  There  must  be 
complete  rest  from  coitus. 

Eczema  of  the  vulva  in  women  and  young  children  is  often 
associated  with  a  similar  state  of  the  anus  and  gluteal  region  by 
extension.  It  is  occasionally  an  evidence  of  a  general  debilitated 
condition  due  to  some  blood  dyscrasia,  occurring  in  lymphatic 
temperaments,  or  strumous  constitutions ;  but  it  is  more  often  due 
to  local  irritative  discharges,  or  perhaps  pediculi.  The  eruption  is 
often  of  the  impetiginous  character ;  the  part  is  hot,  tender,  and 
smarting.  Pustules,  vesicles,  scabs,  and  excoriation  of  the  skin  and 
mucous  membrane  follow. 

Such  a  case  I  had  recently — the  excoriation  extended  from  the  sacrum 
behind  to  the  umbilicus  in  front.  It  was  the  most  extensive  I  have  seen. 
The  patient  was  ultimately  completely  cured  by  curettage  of  the  uterus ; 

*  See  Treatment  of  Vaginismus. 


Fig.  535a. — C'akcixoma  of  the  VrLVA.     (Noble.) 

This  began  as  a  small  sore  about  the  vestibule,  which  was  ultimately  involved  by 
the  formation  of  a  corroding  ulcer,  extending  to  the  urethra  and  the  vaginal 
orifice.  The  entire  vulva  was  congested.  Xoble  ablated  the  involved  parts 
and  sutured  the  skin  external  to  the  labia  majora  down  to  the  urethra,  and 
approximated  it  to  the  vaginal  mucous  membrane.  Two  years  after  the 
operation  there  was  no  recurrence.* 


*  AiiK^r.  Jour.  Obstet.,  vol.  xlii.,  1900. 


ITofacep.  810. 


^.    ;    •     '         *  ^B 

ll^k.     J 

^^^!' 

'','.  -jPp.       1^''        1 

Hi 

^         '"^%'            -jfl 

Fig.  535b. — Diffdse  Papillary  Epithklioma  of  the  Clitoris — Ospedale 
Maggiore  di  Milaxo.    (Mangiagalli.) 

[To  face  p.  Sn. 


AFFECTIONS   OF   THE    VULVA.  811 

attention  to  the  acid  urine ;  the  aclministration  of  iclithyol  with  arsenic,  and 
local  packing  with  oil  and  ichthyol  cream  :  Erasnuis  Wilson's  calamine  and 
zinc  lotion  with  salic3dic  acid,  and  the  application  iinally  of  nitrate  of  silver 
solution,  20  grs.  ad  5i.  to  the  raw  and  fissured  surfaces.  (8ee  Treatment  of 
Pruritus.) 

Eczema  of  a  parasitic  oi'igin  is  specially  worthy  of  remembrance 
ill  the  case  of  the  vulva,  which  partakes  so  largely  of  the  conditions 
favouring  parasitic  growth.  In  fact,  Eichoff  prefers  the  name 
'  dermatitis  parasitaria '  to  eczema,  under  such  circumstances,  or  to 
Unna's  '  eczema  seborrhteicum.' 

Treatment. — Any  constitutional  fault  has  to  be  carefully  attended 
to  and  corrected.  The  muslin  dressing  ointments  of  Unna  are 
admirable  applications  in  such  eczematous  and  other  morbid  vulvar 
states.  These  can  be  doubled  so  as  to  expose  a  surface  of  ointment 
to  each  labium,  and  retained  thus  in  the  vulva.  They  may  be 
had  of 

Lsr.d,  Arsenic, 

Carbolic  acid.  Belladonna, 

Ichtliyol,  Chloral, 

Oxide  of  zinc,  Camphor, 

Oxide  of  zinc  and  salicylic  acid,  Creosote, 

Oxide  of  zinc  and  thymol,  and 

'J'hymol,  Mercuric  perchluriJe, 

l^°^-i«  '^«id'  Chrysophanic  acid,    (  "^^^  "!<^  ^"  ^'^ 

Europhen,  ^J^J  chronicstages 

Iodoform,  (  of  the  disease. 

lodol,  Mercury, 

Nitrate  of  silver  solution. 

Some  of  the  washes  enumerated  in  the  treatment  of  vaginitis 
will  be  found  most  useful,  especially  those  of  zinc  and  calamine, 
subacetate  of  lead,  thymol,  and  sulpho-carbolate  of  zinc.  It  is  in 
cases  of  eczema  and  pruritus  that  alkaline  bathing  and  the  correc- 
tion of  all  acrid  vaginal  discharges  are  of  such  importance.  The 
liquor  carbonis  detergens  lotion  should,  be  tried  in  the  drier  forms. 

Lassar's  Paste — *  Ihle's  Paste — 
R.     Acidi  salicylici,  grs.  x.  Eesorcini,  grs.  x. 

Ziuci  oxidi,  \   -  -    ••  Zinci  oxidi,   \ 

P.  amyli        J  ^'"^  ''''  P.  amyli,       (    , 


Vaseliui,  5ss.  Lanolini,        I 


la  511. 
Vaselini, 

Herpes. — Herpes  of  the  type  of  H.  Zoster  is  occasionally  found 
^  Kecommended  by   Graham   of    Toronto    (Ann.    Universal   Med.   Sciences, 


isys). 


812  DISEASES   OF   WOMEN. 

following  in  the  course  of  the  pudendal  nerves.  It  must  not  be 
mistaken  for  a  specific  eruption.  If  a  herpetic  eruption  occur  on 
the  vulva,  it  is  an  indication  for  the  administration  of  such  tonics 
as  the  mineral  acids  with  bark  and  quinine,  generous  diet,  and  a 
soothing  local  treatment,  as  in  the  case  of  eczema.  When  the 
vesicles  spread,  and  there  is  a  tendency  to  pustulation,  they  should 
be  brushed  over  with  a  solution  of  nitrate  of  silver  (grs.  xxx. 
ad  ^i),  which  is  permitted  to  dry,  and  then  a  muslin  dressing  may 
be  applied.  Outside  the  vulva  the  zinc  (with  calamine)  lotion  is  a 
soothing  application. 

Herpes  Vegetans  of  the  Vulva. — Bataille  exhibited  a  case  at  the  '  Societe 
de  ■Dermatologie  et  de  Syphiligraphie  '  ia  which  there  was  no  history  of  ac- 
quired or  hereditary  syphilis.  Following  a  foul  discharge  from  the  vagina 
and  general  s3^mptoms  of  pyrexia,  there  was  an  eruptiou  of  herpetic  vesicle^, 
which  sprea'l  from  the  groin  to  the  vulva,  and  to  the  anal  fold.  The  swollen 
vulva  was  covered  with  vascular  erosions,  which  had  in  parts  a  diphtheroid 
appearance,  so  much  so  as  to  give  to  the  erosion  a  chancroid  look  One  of 
these  erosions  was  at  the  orifice  of  the  in-ethra.  The  cervix  uteri  was 
swollen  and  red,  tlie  lips  were  everted,  and  theie  was  a  muco-purulent 
secretion  from  the  uterus,  vesicles  were  seen  on  the  tonsils,  and  the  sub- 
mental ganglia  were  enlarged.  After  successive  formations  of  vesicles  had 
occurred,  the  ulcerations  in  healing  developed  vegetations  resembling  syphilitic 
ulcers,  of  a  violaceous  red  colour,  Avith  bleeding  surfaces,  most  difficult  to 
diagnose  (Fournier).  The  possible  occurrence  of  such  suspicious  vegetations 
on  the  vulva,  without  any  syphilitic  history  to  connect  them  with  specific 
infection,  should  be  borne  in  mind.* 

Pediculi  frequently  infest  the  vulva.  In  cases  of  eczema  and 
pruritis  they  should  be  carefully  looked  for.  It  is  necessary  to  use 
a  lens  for  this  purpose.  The  ammonio-chloride  of  mercury  powder 
diluted  with  starch  may  be  lightly  dusted  on  the  part,  or  the 
ointment  of  mercury  or  stavesacre  rubbed  in,  or  the  perchloride  of 
mercury  lotion  applied.  One  part  of  carbolic  acid  to  seven  of  oil  is 
a  useful  application. 

Pruritus. — The  practitioner  must  not  fall  into  the  error  of 
regarding  pruritus  as  a  primary  disease  rather  than  as  a  secondary 
aflfection  of  the  vulva.  Pruritus  must  be  looked  on  as  a  neurosis, 
secondary  to  a  constitutional  error  of  nutrition,  or  to  some  local 
disease  in  any  part  of  the  genital  tract.  The  danger  lies  in  the 
mistake  of  treating  a  symptom  and  neglecting  the  disease  which 
originated  it.  We  may  thus  divide  the  causes  of  pruritus  of  the 
vulva  into  constitutional  and  local, 

*  Annals  de  Dermatologie  et  de  Syphiligraphie,  Paris,  p.  298 ;   Annual  of 
Universal  Medical  Science,  1898. 


AFFECTldNS   OF    THE    VULVA.  81 1? 

Causation. — J.  C.  Webster  considers  pruritus  to  be  a  subacute  innanimation 
of  the  papillcX!  of  the  skin,  and  a  progressive  fibrosis  of  the  nerves  and 
Paccinian  bodies,  especially  attacking  the  clitoris  and  the  upper  parts  of  the 
labia  minora.  It  is  in  the  main  an  inflammatory  affection  of  the  cerium 
(vulvitis  prurigiii osd). 

Sanger  *  considered  that  the  lesion  of  the  nerve-ends  is  not  the  jjrimary  cause 
of  tlie  pruritus,  but  a  secondary  change,  resulting  from  a  local  affection  of  the 
vulva,  due  to  the  action  of  the  irritants  from  without.  He  maintained  that 
there  was  no  proof  forthcoming  that  micro-organisms  can  induce  the  skin 
lesions.  It  was  more  probable  that  their  presence  was  secondary  to  pre- 
existing local  affections,  and  if  micro-organisms  were  the  primary  cause  of 
vulvitis  pruriginosa,  we  should  get  this  affection  accompanying  all  cases  of 
catarrh  of  the  bladder.    He  subdivided  the  affection  into  two  great  groups — ; 

I.  Endogenous  Causics. — (1)  Conditions  of  the  Mood.  Icterus,  chronic 
nephritis,  diabetes  mellitus.  (2)  Circulatory  causes.  Haemorrhoids,  heart 
disease,  pregnancy,  retroflexion,  and  tumours  of  the  uterus  (the  latter  by  local 
obstruction  to  circulation).  (3)  Skin  diseases  (of  hsematogenous  origin). 
Erythema,  urticaria,  herpes,  eczema. 

II.  Exogenous  Causes. —  (1)  Secretory  causes.  H^^Deridrosis  and  seborrhoea, 
vaginal  and  uterine  discharges.  (2)  Parasitic  causes.  Animal  parasites  : 
pediculi,  oxyuris  vermicularis.  Vegetable  parasites :  leptothrix,  oidium 
albicans,  micrococcus  urese.  (3)  Mechanical  causes.  Masturbation.  (4) 
Thermal  causes.     Spring  and  summer  pruritus. 

It  must  be  remembered  that  many  of  these  local  causes  enumerated 
in  the  text  only  cause  severe  itching,  not  true  pruritus.  For  clinical 
purposes  I  here  group  those  conditions  incidental  to  and  often 
associated  with  pruritus. 

Constitutional —  Local — 

Gout.  Eczema. 

Diabetes.  Lichen. 

Gonorrhoea.  Leucorrho^al  discharges. 

Exanthemata.  Gonorrhoeal           ,, 

The  menopause.  Plow  of  diabetic  urine. 

Pregnancy.  Cystitis. 

Senile  changes.  Vulvitis. 

Hysteria.  Vaginitis. 

Bright's  disease.  Endometritis. 

Alcoholism.  Ascarides. 

Gastric  and  hepatic  derange-  Pediculi. 

ments.  Vegetations. 

(Of    these,   diabetes,  alcoholism.  Urinary  fistulse. 

pregnancy,     and    ga,stric    de-  Haemorrhoids. 

rangements     are     the      most  Uncleanliness. 

frequent.) 

*  CeiiimW.f.  Gijn.,  Feb.  1894. 


814  DISEASES   OF    WOMEN. 


In  many  severe  cases  of  pruritus  there  is  a  total  absence  of  all 
organic  change  in  the  skin,  and  the  irritation  is  due  to  some  gastric, 
hepatic,  or  rectal  affection.  In  senile  cases  there  is  frequently  a 
want  of  cleanliness,  a  dryness  of  the  parts,  and  a  gouty  state  of  the 
system.  In  a  great  many  instances,  however,  the  excoriation  and 
accompanying  eruption  are  secondary  consequences  of  some  irritating 
discharge,  and  the  tearing  of  the  skin  by  the  nail  in  scratching. 

Intractable  Pruritus  with  Vaginismus,  and  Dyspareunia  associated 
with  Fissure  of  the  Vaginal  Fourchette  and  Uterine  Erosion- 
Cure. 

A  patient  suffered  for  some  years  with  intractable  pruritus,  and  for  some 
considerable  time  from  such  a  degree  of  dyspareunia  that  the  pain  prevented 
all  marital  relationships.  On  examination  I  found  a  vaginal  discharge  with 
a  slight  cervical  erosion.  The  vulva  was  dotted  over  with  aphthous  patches 
and  some  erosions.  Extending  back  through  the  fourchette,  for  about  half  an 
inch,  was  a  fissure,  which  she  said  had  lasted  for  some  time.  There  was 
a  general  condition  of  vaginismus,  and  the  parts  were  intensely  sensitive. 
Her  misery,  however,  appeared  to  entirely  centre  itself  in  the  pruritus,  which 
was  influencing  her  health  from  constant  irritation  and  sleeplessness.  The 
whole  vulva  was  shaved,  and  thoroughly  disinfected.  The  uterus  was  curetted 
out,  and  chromic  acid  applied  to  the  cavity.  The  erosion  of  the  cer^ax  was 
treated  with  nitric  acid.  The  spots  on  the  vulva  were  all  touched  with  carbolic 
acid.  By  an  elliptical  incision  from  side  to  side,  the  fissure  was  exsecttd,  and 
the  vaginal  orifice  enlarged.  The  entire  area  of  the  itching  surface  was  well 
rubbed  with  pure  carbolic  acid.  This  application  was  repeated  a  second  time. 
The  vagina  was  tamponed  with  chinosol  gauze,  and  for  a  week  subsequently 
the  urine  was  carefully  drawn  off,  and  the  closest  attention  paid  to  the  clean- 
liness both  of  the  vagina  and  vulva.  The  patient  left  completely  cured  of  the 
itchin"-,  and  bearing  the  introduction  of  the  largest  vaginal  dilator  without 
distress. 

Kraurosis  Vulvas. —  Briesky,  Orthmann,  Martin,  and  Sanger  are 
the  principal  authors  to  whom  we  Urst  owed  our  knowledge  of  this 
affection.  It  does  not  appear  to  have  any  microbial  origin,  nor  is  it 
associated  with  any  venereal  affection.  The  nerve-ends  are  not 
changed  as  in  pruritus.  It  is  a  question,  according  to  Siinger,  if 
it  be  not  a  form  of  atrophic  change  in  the  vulva,  preceded  by  an 
inflammatory  state.  It  is  not  peculiar  to  women  of  any  age,  nor 
has  married  life  anything  to  say  to  it. 

This  shrivelled  condition  of  the  vulva,  associated  in  places  with 
fissures,  and  possibly  in  other  parts  with  swollen  and  red  portions 
of  skin  about  the  vulva  and  the  labia  majora,  attended  by  intoler- 
able itching  (though  this  latter  symptom  is  not  invariably  present), 


AFFECTIONS   OF   THE    Vl'LVA.  815 


is  the  characteristic  of  kraurosis  vulvae.  The  parts  about  the 
vestibule  are  often  white,  and  the  labia  minora  have  a  wash-leather 
appearance.  Veit  regards  the  affection  as  a  sequence  of  pruritus, 
and  Yung  *  considers  that  chronic  indammation  is  the  source  of 
the  kraurosis,  and  that  there  is  nothing  special  in  the  type  of  this 
condition,  which  may  have  as  its  antecedents  either  gonorrhoea, 
pruritus,  tuberculosis,  or  carcinoma.  Heller  agrees  as  to  the 
chronic  intlammatory  nature  of  the  disease,  which  leads  to  the  dis- 
appearance of  the  fat  and  sebaceous  glands  and  the  gelatinous 
matter,  bringing  about  a  hypertrophic  process  in  the  more  super- 
ficial layers  (hyperkeraktosis). 

There  is  usually  itching,  but  this  symptom  is  not  invariably 
present,  being  absent  when  there  are  serious  atrophic  changes  in 
the  nerves.  The  swelling  and  feeling  of  tension  are  followed  by 
fissures,  and  subsequently  atrophic  changes  in  the  tissues  of  both 
the  labia  and  clitoris. 

Heller  obtained  complete  clinical  relief  from  all  the  symptoms  by 
the  application  of  formalin  to  the  harder  portions  of  the  affected 
area,  also  using  ichthyol  as  a  pigment. 

Kraurosis  associated  with  Cervical  Polypus  and  Anal  Fissure. 

Iq  a  case  uuder  my  care  the  labia  minora  and  the  inner  surfaces  of  tlie 
labia  majora,  as  also  the  fourchette,  had  assumed  a  thickened  and  white 
''  washleather  "  appearance.  There  was  a  fissure  of  the  anus  associated  with 
the  s-ulvar  trouble.  There  was  also  a  small  cervical  polypus  with  accom- 
panying vaginal  discharge.  The  anal  fissure  and  the  polypus  were  first 
cured.  Emollient  baths  were  used  daily  for  a  prolonged  period,  and  by 
constant  application  of  nitrate  of  silver  (20  grs.  to  the  ounce},  with  which  the 
affected  skin  was  regularly  scrubbed,  and  the  use  at  night,  after  the  baths,  of 
an  ichthyol  cream  with  occasional  absorbents  (as  the  ointment  of  red  oxide 
of  mercury  and  iodide  of  potassium),  the  parts  ultimately  recovered  their 
normal  condition  and  appearance.  There  was  in  this  case  a  relationship 
between  the  occun'ence  of  the  kraurosis  and  the  anal  imtation  with  the 
vaginal  discharge,  due  to  the  polypus  of  the  cervix,  as  they  commenced 
coincidentally. 

In  severe  cases  recourse  must  be  had  to  ablation  of  the  affected  areas. 

Treatment. — On  first  seeing  a  case  of  pruritus  we  should  inquire 
cai'efully  into  the  origin  and  history  of  the  disease.  Our  success  in 
overcoming  the  obstinate,  and  at  times  intractable,  itching  will 
depend  on  the  discovery  of  the  cause,  whether  constitutional  or 
local,  which  has  brought  on  the  pruritus.     Gouty  and  diabetic  states 

*  Miinnh.  m.  Wdus..  1903,  Xo.  4n. 


81  fi  DISEASES   OF    WOMEN. 

must  be  dealt  with  according  to  general  principles,  both  therapeutical 
and  dietetic ;  the  character  of  the  urine  should  be  ascertained,  and 
any  abnormal  condition  of  this  secretion  rectified  as  far  as  possible. 
The  diet  has  to  be  carefully  regulated.  Alcohol,  according  to  cir- 
cumstances, should  either  altogether  be  forbidden  or  taken  in  the 
most  moderate  quantity.  Sufferers  from  pruritus  should  avoid  too 
stimulating  a  diet.  Tea  and  coffee  must  only  be  taken  in  modera- 
tion. Saccharin  in  diabetic  and  gouty  cases  is  a  most  valuable 
substitute  for  the  ordinary  carbo-hydrate  sugar.  Food  should  be 
simple  and  plainly  cooked.  Pastry,  fats,  rich  soups,  sweets,  cheese, 
shell-fish,  saccharine  vegetables,  and  fermented  drinks,  should  be 
avoided. 

In  hepatic  derangement,  the  administration  of  a  mild  mercurial 
preparation  a  few  times  in  the  week  at  night,  in  combination  with 
a  vegetable  cholagogue,  followed  by  the  administration  of  a  saline 
water  the  next  morning,  such  as  Rubinat,  Hunyadi  Janos,  or 
Victoina  water,  will  be  of  service.  The  Carlsbad  salt  in  powder 
or  crystal,  dissolved  in  warm  water,  is  beneficial.  Svich  spas  as 
those  at  Vals,  Vichy,  Yittel,  Contrexeville,  Ems,  Homburg, 
Carlsbad,  Kissingen,  Bourboule,  Aix-les-Bains,  Harrogate,  Bath, 
Cheltenham,  and  Strathpeffer,  can  be  recommended  according  to 
the  type  of  case.  During  pregnancy  the  patient  may  take  sijitable 
soothing  baths,  and  use  such  local  remedies  as  some  of  those  in  the 
subjoined  list.  The  leucorrhoeal  discharge  of  pregnancy  should  be 
attended  to.  If  there  be  constitutional  syphilis,  it  must  be  dealt 
with  by  specific  remedies,  both  general  and  local.  Arsenic  will  be 
found  of  service  in  many  cases. 

Local  Treatment. — The  first  care  of  the  physician  will  be  to 
endeavour  to  rectify  any  uterine,  vesical,  or  rectal  affection  that 
may  complicate  the  pruritus. 

Much  benefit  will  be  derived,  ift  some  cases,  from  the  use  of 
soothing  alkaline  and  starch  baths.  But  to  this  there  are  excep- 
tions ;  and  baths  occasionally  appear  to  do  more  harm  than  good. 

The  three  baths  I  prefer  are — • 

1.  Bran  (2  lb.),  potato-starch  (^  lb.),  gelatine  (1  lb.) ;  water  at  100°— 

105°,  25  to  30  gallons. 
To  this  a  hvf  gallons  of  decoction  of  marsli-mallow  may  be  added.     The  bran 
and  marsh-mallow  water  can  be  first  prepared,  and  added  to  the  bath  sub- 
sequently. 

2.  Carbonate  of  sodium  Q,\\.),  hyposulphite  of  sodium  (,^ii.),  potato-starch 

(Siv.) ;  water  at  100°— 105°,  25  to  30  gallons. 


AFFECTIONS   OF  THE    VULVA.  817 


3.  Liq.  carbonis  detcrgens  (Wrights's),  3!. — 5ii.  to  the  gallon. 

4.  The  Bareges  batli  or  that  of  liopar  sulphuris,  the  objection  to  which  is 

its  odour  and  its  cll'ect  on  the  surface  of  the  bath. 

In  ordering  any  liot  bath  for  a  female  patient,  the  periods  must 
be  remembered,  and  their  regularity  inquired  into.  If  there  he 
suppression  uf  the  menstrual  JIoiv  and  accompanying  head-symptoms, 
such  as  headache,  disturbances  of  vision,  or  tinnitus  aurium,  hot  baths 
should  not  be  talcen.  Such  soaps  as  larch-soap  (W.  Moore) — which  is 
composed  of  wheaten  bran,  glycerine,  white  curd  soap,  and  extract 
of  larch-bark — sulpholine  soap,  molfa  (Dinneford),  resinal  and 
carbolic  or  tar  soap,  may  be  used  with  the  bath.  A  glycerine  or 
medicated  tamjDon,  or  pessary,  can  be  introduced  after  the  bath. 
(The  bath  speculum  is  shown  at  p.  67.)  The  vaginal  rest  may  be 
worn,  and  the  lips  of  the  vulva  separated  by  a  piece  of  folded  linen 
or  cotton-wool,  smeared  over  with  any  sedative  ointment,  or  the 
muslin  ointments  before  referred  to  can  be  prescribed,  and  these 
may  be  kept  in  position  by  a  light  perineal  bandage  or  a  napkin. 

The  local  remedies  which  will  be  found  of  use  either  in  washes  or 
ointments  to  allay  itching  have  been  already  enumerated.  Those  I 
attach  most  value  to  are — 

In  lotion — 

Hydrocyanic  acid  (min.  v. — ^i.). 

Perchloride  of  mercury  (1  in  2,000—1  in  5,000). 

Tobacco,  as  infusion  (3!. — Oi.). 

Solution  of  subacetate  of  lead  (5ii. — ^x.). 

Chloral  (gr.  x.  ad  ^i.). 

Cocaine  (5 — 10  per  cent,  solution). 

Chloroform  (1  pt.  to  7  of  oil). 

Menthol  (1  pt.  to  7  of  oil). 

Liq.  carbonis  detergens  (3!. — ^viii.). 

Ext.  hamamelis  liq.  (^i.  in  ^viii.). 

Walnut  leaves  (decoction  of). 

Calomel  (lotio  nigra). 

In  ointment — • 

Salicylic  acid  (grs.  xx.  ad  ^i.). 

Pyroligneous  oil  (31.  ad  ^i.). 

Cj^anide  of  potassium  (gr.  ii. — gr.  v.  ad  5i.). 

Morphia  (gr.  v.  ad  ^i.). 

Cocaine  (gr.  xx.  ad  5i.). 

Belladonna  (gr.  x. — xx.  ad  Ji.). 

Oleate  of  mercury  and  morphia  (lanolated). 

Cuticura. 

3    G 


818  DISEASES    OF    WOMEN. 


Neisser  strongly  recommends  tumenol  as  anti -pruritic  in  eczematous  states 
and  in  prurigo.  He  uses  the  remedy  either  as  a  paste  (5-10  per  cent,  of  the 
powder  with  starch)  or  as  an  ointment.* 

Many  of  these  remedies  must  be  used  with  caution,  especially  if 
there  be  abraded  surfaces,  as,  for  instance,  cocaine,  perchloride  of 
mercury,  belladonna,  cyanide  of  potassium,  morphia,  hydrocyanic  acid. 
The  exact  quantity  to  be  applied  should  be  stated  in  the  prescription. 

For  the  itching  of  diabetes  Goodell  strongly  recommends  the 
salicylate  of  sodium,  in  15-grain  doses,  every  fourth  hour.  Bromides 
and  chloral,  trional,  sulphonal,  chloralamide  or  urethane  may  be 
given  to  secure  rest  and  sleep. 

The  following  astringent  and  antiseptic  applications  will  also  be  found  most 
vakiable  affections  of  the  vulva,  in  strengths  indicated  according  to  the  special 
cases. 

Oxide  of  zinc   \    ,2  ,      z  ••■  \ 

Calamine  )    ^•^*^^'     ^^'"•''' 

Biborate  of  sodium  (jii. — ^viii.). 

Carbonate  of  sodium  (5ii. — ^viii.). 

Acetate  of  lead  (gr.  ii. — gr.  iv. — 5i.). 

Solution  of  the  subacetate  of  lead  (3ii. — o"^^'"-)- 

Sozo-iodolate  of  sodium  (3ii.  in  ^viii.). 

Sulpho-carbolate  of  zinc  (gr.  iv. — ^i.). 

Thymol  (1  in  500  to  1  in  1,000). 

Chaulmaugra  oil  with  almond  oil  (1  part  to  2). 

Camphor  and  borax  (liq.  camphor,  concent.  3 ii.,  borax  3iv.,  in  jviii., 
with  or  without  glycerine). 

Nitrate  of  silver  (gr.  xxx. — 3i.  ad^i.). 

Carbolic  acid  (gr.  xxx. — 3i.  ad  ^i.,  or  equal  parts  of  carbolic  and 
glycerine). 

Chromic  acid  (gr.  xxx.  ad  ^i.)- 

Chloride  of  zinc  (gi\  xxx.  ad  ^i.). 

And  as  lanolated  ointments — 

Benzoate  of  zinc  (3i. — ji.). 

Oxide  of  zinc  (3i. — ^i.). 

Chloroxide  of  bismuth  (3ii.^-^i.).     These  may  be  combined. 

Glycerole  of  lead  (3!. — .^i.). 

Oleates  of  lead  and  zinc  (3SS. — ^i.). 

Eed  oxide  of  mercury  (gr.  xxx. — ^i.  ad  ^i.). 

Sozo-iodol  (3i.  ad  ^i.). 

lodol  (3SS. — 3i.  ad  ^ii.). 

Iodoform    (disguised   with  fresh   coffee,    equal   parts,    vanillin    or 

coumarin,  gr.  v.)  (3ss.— 3i.  ad  ^i.).- 
Pyroligneous   oil   of  juniper    (alone   or   in    combination,    varying 

strengths). 

*  Deutsche  Med.  Wchns.,  Leipzig,  Nov.  5,  1891. 


AFFECTIONS   OF   THE    VULVA.  810 


The  use  of  any  of  the  remedies  here  enumerated,  whether  alone 
or  in  conil)ination,  will  depend  on  the  nature  of  tlie  eruption,  its 
stage,  and  the  indication  for  a  soothing,  astringent,  stimulating,  or 
detergent  application.  It  is  wrong  to  commence  with  too  powerful 
an  application.  It  is  better  to  begin  with  a  mild  lotion,  and  increase 
its  strength  according  to  the  toleration  of  the  part.* 

Where  there  is  a  raw  or  moist  surface  of  the  skin  the  lotion  of  zinc  and 
calamine  (Wilson)  will  be  found  most  useful.  To  this  either  carbolic  acid, 
or  thymol,  or  hydroc^'anic  acid  may  be  added.  It  can  be  used  with  a  fine 
sponge.  The  powder  dries,  and  can  be  washed  off  before  fresh  lotion  is 
applied. 

R     Zinci  oxidi,  5ii.  '  R    Sol.  ichthyol  (10  per  cent.),  5iv. 

Calamine  pur.,  5iv.  i         01.  cbaulmaugrse,  5iv. 

Glycerine,  jii.  !  Lanolini,  5i. 

Aq.  rosaj,  ^viii.     Ft.  lotio.  Ung.  benzoat,  ^\.    Ft.  Ungt. 

The  ointment  should  be  applied  to  the  part  after  the  alkaline  or  tar  bath. 
The  latter  for  a  full  bath  is  made  of  the  strength  of  5i. — .^ii.  of  the  liquor 
carbonis  detergens  to  the  gallon  of  warm  water. 

W^hen  the  inner  surfaces  of  the  labia  or  nymphaB  are  sore  or  swollen  they 
should  be  separated  by  some  emollient  dressing — a  muslin  dressing  of  Unna 
may  be  used — or  a  piece  of  linen  can  be  folded  and  placed  between  the  labia. 
The  linen  can  be  covered  with  any  application  we  may  wish  to  employ. 

Local  Syphilitic  Remedies. 

These  are  the  more  useful  specific  applications  if  the  pruritus  be  associated 
with  syphilis — 


Calomel  wash. 

Oleate  of  mercury  and  morphia. 
Calomel  vapour  baths. 
Iodoform  insufflated. 


Vasol  iodine. 

lodol  ointment. 

Ointment  of  the  red  oxide  of  mercury. 

Mercurial  (mild)  ointment. 


Sozo-iodol  and  its  salts  (ointment  or        Ointment  of  calomel  with  bismuth. 


wash). 
Iodoform  ointment. 
Europlien. 
lodol  insufflated. 


Iodide  of  starch  (ointment  and  powder) 
Liquor  picis  (,5i. — jii.  ad.  ^i.). 
Extract  of  belladonna  (5!. — 51.). 
Cyanide  of  potassium  (gr.  iii. — 51.). 


All  these  may  be  made  with  lanolin.  Alanolated  ointment  is  more  readily 
and  completely  absorbed  by  the  skin.  As  a  rule,  it  is  sufficient  to  add  one 
part  of  fresh  lard  or  benzoated  lard,  with  a  little  rosewater.  to  two  of  lanolin,  as 
a  basis. 


*  Adrenalin.— Peters  has  (Der  Fmuenauit,  Nos.  1  and  2,  1904)  used  with 
complete  success  various  preparations  of  the  supra-renal  gland  in  pruritus. 
Pads  soaked  with  ^  to  .^^  of  the  solution  were  applied  to  the  afi'ected  area  for 
about  five  minutes  at  a  time,  and  intr  educed  into  the  vagina  at  night. 


820  DISEASES   OF   WOMEN. 

Operative  Treatment. — Sanger,  in  unusually  severe  and  obsti- 
nate cases,  removed  the  diseased  parts.  The  first  operation  for 
pruritus  was  performed  by  Garrard,  in  1874;  he  removed  only 
the  clitoris,  but  a  complete  cure  resulted.  Since  then  similar 
operations  have  been  performed  by  Chrobak,  A.  R.  Simpson, 
Schrceder,  Rheinstadter,  Olshausen,  Kelly,  and  many  others.  Heitz- 
mann  has  obtained  good  results  by  scraping  the  affected  parts. 
Sanger  in  two  cases  excised  the  entire  clitoris,  and  the  labia  majora 
and  minora,  and  combined  with  this  procedure  repair  of  the  peri- 
neum. No  difficulty  was  experienced  in  closing  the  wound,  and 
after  healing  there  was  practically  no  visible  deformity.  Sanger 
considers  that  the  removal  of  the  clitoris  has  no  effect  upon  the 
sexual  appetite  in  women  of  middle  or  advanced  age.  In  both  of 
these  cases  the  sufferings  of  the  patient  disappeared  from  the  day 
the  operation  was  performed.  Sanger  lays  down  the  following 
propositions : — 

(1)  The  partial  or  complete  excision  of  the  vulva  is  a  legitimate  operation, 
which  ought  to  be  performed  in  chronic  cases  of  vulvitis  pruriginosa,  which 
have  resisted  other  methods  of  treatment. 

(2)  The  clitoris  may  he  removed  without  harm  in  all  but  young  women. 

(3)  In  young  women,  and  in  cases  where  the  symptoms  are  localized  to  a 
part  of  the  vulva,  only  the  diseased  portions  should  be  removed. 

(4)  In  older  women,  and  when  the  vulva  is  extensively  affected,  the  entire 
vulva  should  be  removed,  and  the  parts  restored  by  plastic  methods. 

Rodent  Ulcer. — This  very  rare  form  of  malignant  disease  does  not 
differ,  save  in  so  far  as  it  is  influenced  by  the  anatomical  site  in  which 
it  occurs,  from  the  same  disease  elsewhere,  and  may  be  considered 
an  epithelioma.  The  treatment  is  conducted  on  the  same  principles 
which  determine  us  in  the  management  of  rodent  ulceration  occur- 
ring in  other  situations.  If  by  the  hard  base,  slow  progress,  and 
absence  of  pain,  we  should  be  able"  to  recognize  the  disease  early 
and  before  ulceration  has  extended  widely  or  deeply,  we  may  prevent 
the  spread  of  the  growth  by  the  knife  and  caustics,  the  most 
powerful  of  the  latter  being  potassa  fusa,  chloride  of  zinc,  and 
nitric  acid.  We  must  be  careful  to  distinguish  it  from  syphilitic 
ulceration,  and  from  what  few  are  likely  to  see  in  a  lifetime — 
so-called  '  lupus  of  the  vulva,' 

Cancer  of  the  labium,  occurring  generally  in  advanced  life,  is  not  a 
common  disease.  The  form  in  which  it  is  most  frequently  met  with 
is  that  of  cancroid.  Epitheliomatous  nodules  may  exist  for  some 
time,  and  give  rise  to  little  pain.    It  is'  not  until  \zlceration  commences 


AFFECTION.'^   OF    THE    VULVA.  821 

that  much  uneasiness  is  felt.  The  inguinal  glands  become  involved. 
It  is  difficult,  save  by  careful  microscopical  and  bacteriological 
examination,  to  distinguish  such  nodules  from  syphilitic  neoplasms, 
or  'lupus.'  Kelly  has  reported  a  case  of  adeno-carcinoma  of  the 
vulvo-vaginal  gland. 

Papillary  Cystoma  of  the  Vulva. — Polity  has  recorded  *  a  case 
of  proliferatini,'  papillary  cystoma  in  the  riglit  labium  minus.  The 
nodules  were  discovered  during  an  operation  fijr  prolapse.  The 
larger  simple  cyst  contained  cubical  cells  springing  from  the  epi- 
thelial proliferation  of  the  internal  surface  of  its  wall,  while  the 
smaller  tumour  was  composed  of  a  large  number  of  small  cysts 
formed  by  connective  tissue  partitions  springing  from  the  wall  of 
the  mother  cysts.  Polity  considered  the  cyst  to  be  '  new  forma- 
tions, the  connective  tissue  being  at  first  active,  and  subsequently 
yielding  to  the  activity  of  the  epitheUal  cells.' 

Treatment. — If  superficial,  it  is  better  to  remove  the  mass  with 
the  knife  and  use  the  actual  cauteiy  to  the  raw  surface,  Hfemor- 
rhage  is  always  to  be  dreaded.  Should  it  occur,  powerful  styptics 
or  the  actual  cautery,  and  a  firm  compress  applied  with  a  bandage, 
will  be  necessary.  Despite  all  efforts,  fatal  bleeding  has  resulted  in 
advanced  cases. 

Oozing  Papillomatous  Tumour. — I  Lave  seen  one  case  of  this  rather  rare 
affection,  presenting  exactly  the  clinical  features  described  by  Emmet  under 
this  name.  The  woman,  about  thirty,  was  unmarried.  There  sprouted  from 
one  labium,  extending  round  the  fourchette  to  the  other,  a  large  red  ras[)berry- 
looking  mass,  bleeding  rather  profusely  on  examination,  painless,  and  secreting 
an  oftensive  discharge.  It  was  a  most  characteristic  growth,  and  had  attained 
a  large  size  before  the  patient  came  into  the  hospital.  An  effort  was  made 
with  ligature  and  cautery  to  remove  it,  but  the  haemorrhage  was  so  great  it 
was  not  possible  to  proceed.  I  do  not  know  what  the  sequel  of  the  case  was. 
Emmet's  reported  case  recovered,  though  here  also  there  was  alarming 
bleeding.f 

Syphilis. 

Care  has  to  be  taken  when  searching  for,  and  in  the  recognition 
of,  primary  syphilitic  sores.  They  frequently  are  seen  on  the 
opposing  surfaces  of  the  mucous  membrane.     They  are  either  true 

*  Arcliiv.  di  Ostet.  e  Gin.,  April,  1903. 

+  Bartholin's  Gland. — Fritsch  has  reported  a  case  of  papilloma  which  origi- 
nated in  the  polynuclear  cylindrical  epithelium  of  the  duct  of  Bartholin.  It 
was  a  mushroom-like  growth  in  the  right  nympha  of  a  woman  aged  77.  The 
vaginal  glands  were  involved.  The  growtli  and  nympliie  were  removed  (^Mounts, 
f.  Gel.  u.  Gyn.,  bd.  xix.  60). 


822  DISEASES   OF    WOMEN. 

chancres,  chancroid  sores,  or  may  assume  the  sloughing  or  phage- 
denic type.     Chancres  are  also  found  on  the  perineum  and  anus. 

Secondary  syphilitic  eruptions  are  frequently  met  with  about  the 
labia  and  perineum,  extending  to  the  anus  and  gluteal  folds. 

Evidences  of  Syphilitic  Infection. — It  may  be  well  here  to  append  a  short 
table  of  the  principal  signs  on  which  we  rely  as  collateral  evidence  of  consti- 
tutional syphilis — 


Granular  enlargements  in  the  groins. 

Symmetrical  skin  affections,  as  macu- 
la), papules,  or  roseola. 

Symmetrical  throat  eruptions  and 
ulcers. 

Condylomata,  syphilitic  vegetations, 
and  warts  on  the  labia. 

Palmar  syphiloderm. 

Syphilitic  changes  in  the  nails. 

Falling  out  of  the  hair. 

Nodes. 

Ozsena. 


G-eneral  discolouration  of  the  skin. 
White    cicatrices   and   scars   on  the 

body. 
Iritis  and  retinitis. 
Stricture  of  the  rectum. 
Gumma ta,  sores,  fissures,  and  ulcers 

of  the  tongue. 
Frequent  abortions  and  miscarriages. 
Nasal  and  naso-pharyngeal  discharges 

attended   with   ulceration   of    the 

mucous  membrane  or  perforation 

of  the  septum  nasi. 


In  the  treatment  of  primary  sores,  the  vulva  should  be  frequently 
dressed  with  subchloride  of  mercury  lotion,  and  washed  with  per- 
chloride  occasionally.  At  night  an  iodol,  A'asol  iodine,  or  iodide 
of  starch  ointment  may  be  used,  or  whatever  muslin  dressing  is 
selected.  The  best  method  of  administering  mercury  is  by  inunc- 
tion or  hypodermic  injection.  The  mercury  may  be  given  up  to  the 
point  of  its  therapeutical  manifestation,  which  is  watched  through 
its  effect  on  the  gums,  and  the  administration  must  always  be  care- 
fully supervised. 

In  many  cases  of  secondary  and  tertiary  affection  the  tannate  of  mercury 
in  gr.  ss. — gr.  i.  doses,  either  alone  or  combined  with  quinine,  or  with  quinine 
and  arsenic,  gives  excellent  results. 

In  secondarj^  syphilitic  neoplasms  and  exanthems  in  women,  an  excellent 
combination  is — 

R     Acid,  arseniosi,  gi-.  ,}^. 
Hyd.  bicyanidi,  gr.  -^^. 
Quinse  sulph.,  gr.  i. 
Ext.  gent,  q.s. 
Micse  panis.     Ft.  pil. 

During  its  administration,  the  iodides  of  sodium  and  potassium  may  be  taken 
in  full  doses. 

Iodoform  (in  gr.  i. — gr.  ii.  doses,  in  pill,  three  times  daily),  when 
it  can  be  borne,  acts  more  quickly.  The  mixture  of  the  iodides  of 
sodium,  potassium,  and  ammonium  in  combination  with  bark  may 


AFFECTIONS   OF    THE    VULVA.  823 


be  given  freely  diluted  with  water,  to  avoid  iodism.  Women  suffer- 
ing from  specific  affections  require  plenty  of  light  nourishing  food, 
change  of  air,  and  a  continuance  of  anti-syphilitic  remedies  for  some 
time.  Mercury,  whether  by  vapour  or  inunction,  should  l)e  given 
with  great  care,  ceasing  the  adtninistratiou  from  time  to  time,  and 
never  pushing  its  therapeutical  effects  to  the  limit  of  salivation.  As 
local  applications  to  syphilitic  sores,  to  clean  their  surfaces,  and  to 
encourage  healing,  iodoform,  iodol,  and  iodide  of  starch  (in  the  form 
of  ointments)  are  excellent.  For  sores  about  the  anus,  black  oxide 
of  mercury  lotion,  bismuth  and  calomel  ointment,  and  calomel 
fumigation  are  most  useful.  Touching  with  a  pencil  of  sulphate  of 
copper  is  beneficial. 

Especially  during  the  secondary  and  tertiary  stages  (the  '  exan- 
them  period  '  of  syphilis),  a  sojourn  at  Aachen  for  at  least  from  five 
to  six  weeks  is  the  most  eflicacious  treatment  we  can  adopt.  It 
consists  in  a  graduated  course  of  mercurial  inunction  under  skilled 
rubbers,  with  baths,  or,  in  severe  cases,  mercurial  subcutaneous  in- 
jections. The  diet,  bathing,  exercise,  and  friction  are  all  carefully 
regulated.  I  have  never  sent  a  syphilitic  case  to  Aachen  that 
was  not  greatly  benefited  if  the  course  were  sufiiciently  long.  For 
those  who  cannot  go  abroad  the  same  course  may  now  be  taken  at 
Harrogate  or  Buxton. 

Vulvitis. 

Simple  Vulvitis — Causes. — This  affection  is  frequently  the  result 
of  want  of  cleanliness,  deficient  food,  exposure,  violent  coitus,  pruri- 
tus, and  the  consequent  rubbing  to  allay  the  itching.  In  children  it 
is  produced  from  the  same  causes,  and  is  occasionally  due  to  the 
irritation  of  threadworms.  In  simple  vulvitis,  the  symptoms  are  : 
swelling,  heat,  irritation,  and  a  leucorrhceal  vulvar  discharge  of 
mucus,  epithelium,  and  pus. 

Purulent  Vulvitis — Causes. — This  is  brought  on  by  want  of 
cleanliness,  traumatic  causes,  gonorrhoea,  excessive  venery,  and  is 
associated  with  vaginitis  and  vaginismus,  pruritus,  vulvar  eruptions 
(as  eczema),  fissure  of  the  vulva,  and  the  exanthemata. 

It  is  a  much  more  serious  form  of  inflammation.  The  pre- 
liminary symptoms  are  all  intensified,  and  are  followed  by  a  copious 
discharge  of  pus.  If  the  labia  be  separated  the  mucous  membrane 
will  be  found  in  parts  excoriated  or  ulcerated,  and  in  some  instances 
patches  of  diphtheritic  membrane  are  seen  on  the  mucous  surface. 


824  DISEASES   OF   WOMEN. 

Besides  the  ordinary  symptoms  of  vulvitis  there  are  frequently 
most  severe  pruritus,  constant  micturition  and  scalding,  with  an 
inflamed  meatus  urinarius.  The  discharge  has  an  unpleasant  odour. 
Cystitis  may  arise. 

Treatment. — The  treatment  must  be  conducted  on  the  lines  laid 
down  for  the  cure  of  vaginitis,  both  simple  and  specific.  It  includes 
rest ;  fomentations  ;  baths  ;  warm  opium  and  acetate  of  lead  lotions  ; 
poultices ;  mild  astringent  and  sedative  applications  when  the  acute 
stage  has  passed ;  an  emollient  ointment,  as  lanolated  zinc  or  oxide 
of  mercury  cream,  is  used  to  separate  the  nymphse.  Later  on,  any 
raw  surface  is  painted  with  a  mild  nitrate  of  silver  solution,  and  an 
antiseptic  and  stimulating  lotion  of  boracic  acid,  sulphocarbolate  of 
zinc,  or  carbonis  detergens,  applied. 

Follicular  Vulvitis.— In  this  variety  of  vulvitis  the  various 
glands — muciparous,  sebaceous,  and  other — of  the  mucous  membrane 
of  the  vulva  are  swollen  and  inflamed.  This  follicular  distension 
often  leads  to  furunculus.  The  minute  boils  recur.  At  times  this 
recurrence  of  the  furunculous  abscess  is  most  distressing  to  the 
patient,  and  is  very  obstinate.  No  sooner  is  one  evacuated  than 
another  appears.  The  boils  vary  in  size.  The  swelling  may  involve 
the  entire  labium  of  one  side.  The  follicles  of  the  portio  vaginalis 
may  also  be  found  swollen  and  suppurating. 

Causes. — It  is  sometimes  associated  with  the  leucorrhoea  of 
pregnancy ;  otherwise  the  causes  operating  in  producing  follicular 
vulvitis  are  much  the  same  as  those  which  induce  simple  vulvitis. 
(See  Vaginitis.) 

Symptoms  and  Signs. — The  same  itching  and  sense  of  burning 
heat,  with  extreme  sensitiveness  of  the  vulva,  that  are  present  in 
other  forms  of  vulvitis,  mark  the  presence  of  the  follicular  varieties. 
Both  the  muciparous  follicles  and  the  sebaceous  glands  are  enlarged  ; 
the  former  in  patches,  the  latter  as  congested  papillte.  There  is 
considerable  pain  attending  the  formation  of  each  tiny  boil.  If  the 
furuncles  assume  a  large  size,  the  suffering  is  great  in  this  sensitive 
part.  The  patient  falls  off"  in  her  general  health ;  she  cannot  take 
exercise,  and  her  appetite  is  affected.  A  most  important  feature  of 
this  inflammation  must  be  remembered ;  it  is  liable  to  cause 
urethritis  in  the  male,  and  thereby  give  rise  to  an  unjustifiable 
suspicion  of  a  married  woman's  chastity. 

Vulvo- Vaginitis  in  Children. —  Erom  the  evidence  collected  by 
Bichard  Woods  (of  Philadelphia)  *  it  appears  clear  that  gonorrhoea 
*  Amer.  Jour.  Med.  Sei.,  Feb.  1903. 


AFFECTIONS  OF  THE    VULVA. 


825 


is  the  c<ause  of  the  genital  inflammation  in  the  great  majority  of 
cases.  Either  a  diplococcus  resembling  the  gonococcus,  or  the  gono- 
coccus  itself,  has  been  found  in  a  large  percentage  of  the  cases  in 
which  the  discharge  has  been  carefully  examined.  Infection  by 
towels,  public  baths,  direct  contact  with  the  male,  and  children 
sleeping  in  the  same  dormitory,  have  been  ascertained  causes  of  the 
affection.  In  several  instances  acute  peritonitis  has  followed  as  a 
complication. 

Dookelski  divides  vulvo-vaginitLs  in  children  into  infectious  or 
non-infectious,  the  former  class  being  subdivided  into  gonorrhoeal, 
diplococcic,  or  simple.     He  considers  that  the  leuchorrhfea  or  '  fluor 


Fig.  53G. — YrLVO-VAOiXAL  Hernia.    (Winckel.) 
(Liable  to  be  mistaken  for  abscess.) 

albus '  of  children  is  in  80  per  cent,  of  cases  of  a  gonorrhceal 
nature,  and  that  in  the  majority  of  cases  the  child  is  infected 
through  the  mother,  which  may  occur  at  the  time  of  birth.  This 
view  of  Dookelski  *  is,  I  believe,  of  too  sweeping  a  character,  and 
I  am  of  opinion  that  there  is  a  larger  proportion  than  20  per  cent, 
of  simple  diplococcic  cases  of  a  non-infectious  character.  Also,  he 
is  hardly  correct  in  saying  that  the  general  constitution  of  children 
has  no  distinct  influence  on  the  course  of  the  disease.  There  is  no 
doubt  that  the  most  severe  cases  are  those  in  which  infection  is 
conveyed  directly  by  immediate  contact.    Though  Bartholin's  glands 

*    Vratch,  April  19,  1903. 


826  DISEASES   OF   WOMEN. 

are  affected  in  gonorrhceal  vaginitis,  microscopical  examination  is 
necessary  to  distinguish  the  form  of  infection. 

Treatment. — The  recurrent  nature  of  folliculitis  is  due  to  auto- 
inoculation  and  the  dissemination  of  the  micrococcus  after  the 
bursting  or  evacuation  of  the  suppurated  follicle.  The  urine  should 
be  examined ;  it  will  be  found  at  times  glycosuric  ;  this  saccharine 
state  of  the  blood  tending  to  promote  fermentative  action  and  the 
development  of  microbal  life.  Any  cervical  or  vaginal  discharges 
must  be  cured.  The  perchloride  of  mercury  (1  in  5000)  or  chinosol 
in  vaginal  douches  may  be  used  a  few  times  in  the  day.  Alkaline 
douches  of  carbonate  and  borate  of  soda  are  soothing.  A  lotion  of 
eau  de  Cologne  in  rosewater  (^i.  in  '^^ui.),  with  dilute  hydrocyanic 
acid,  will  be  found  very  grateful  if  there  be  heat  and  irritation  of 
the  vulva.  The  part  is  first  well  sponged  with  warm  water  con- 
taining one  drachm  to  the  gallon  of  liquor  carbonis  detergens ;  next, 
it  is  thoroughly  dried,  and  the  eau  de  Cologne  wash  is  applied.  At 
night  an  ichthyol  cream  is  smeared  over  the  vulva.  Any  suppurat- 
ing follicles  should  be  laid  open  with  a  knife.  If  a  vulvar  abscess 
forms  it  is  freely  incised.  Irritable  parts  are  painted  with  nitrate 
of  silver  solution. 

Phlegmonous  Inflammation  of  the  Labia. — When  from  any  cause 
we  find  that  one  labium  has  become  enlarged,  tense,  hard,  painful, 
and  very  tender,  we  suspect  phlegmonous  inflammation  j  an  abscess 
generally  follows.  After  opening  a  large  vulvar  abscess  the 
practitioner  should  carefully  see  that  it  heals  well  from  the  bottom 
of  the  wound,  nor  should  the  patient  be  allowed  from  under  observa- 
tion until  it  has  so  healed.  Otherwise  a  sinus  remains  which 
requires  subsequent  free  opening  up,  and  seriously  protracts  the 
recovery  of  the  case.  We  must  treat  the  phlegmon  on  the  general 
principles  of  relieving  pain,  while  promoting  the  formation  and  the 
free  evacuation  of  pus.  Care  must  be  exercised  not  to  mistake 
phlegmonous  inflammation  for  a  hernia,  hydrocele,  or  pudendal 
hsematocele.  An  ovary  may  be  displaced  into  the  vulva.  We  must 
not  commit  the  pardonable  error  of  mistaking  an  inflamed  ovary  for 
phlegmon.  The  presence  of  a  circumscribed  tumour  in  either  labium, 
which  becomes  periodically  sensitive  and  very  painful — this  increase 
of  sensitiveness  corresponding  with  the  menstrual  periods — should 
be  suflicient  to  remind  us  that  an  ovary  may  have  found  its  way 
into  the  labium. 

Abscess  of  the  Vulvo- Vaginal  Glands. — This  affection  of  the 
vulva  and  its  treatment  has  already  been  incidentally  alluded  to. 


AFFECTfONS   OF    THE    VULVA. 


ii'll 


Fig     ■)S7  — Abscess    of    the 
Babtholinian     Gland. 

(HUGUIER.) 


The  position  of  the  tense,  hurd,  painful  swelling,  frequently  attended 
by  a  certain  degree  of  vulvitis,  and  its  sudden  advent,  should  be 
sufficient  indication  of  the  nature  of 
the  inflammation. 

Kelly  describes  an  ingnino-labial  abscess ; 
it  occurred  in  a  mulatto,  and  involved 
both  inguinal  canal  and  the  labium. 

G-angrene  —  Noma.  —  This  serious 
affection  is  fortunately  not  of  frequent 
occurrence.  I  have  seen  one  instance 
in  a  child  in  which  death  occurred, 
never  in  an  adult.  The  predisposing 
causes  are  such  as  we  find  producing 
low  and  unhealthy  types  of  inflamiua- 
tion,  notably  cancrum  oris,  and  those 
sloughing  ecthymatous  sores  frequently 
seen  in  impoverished  and  dirty  chil- 
dren. If  not  checked,  the  course  of  disease  is  that  of  unhealthy 
ulceration  when  attended  by  mortification. 

The  treatment  consists  in  generous  support  of  the  child,  and  the 
application  of  such  disinfectants  as  peroxide  of  hydrogen,  strong 
formalin,  permanganate  of  potash,  carbolic  acid,  chloride  of  zinc, 
iodoform.  If  any  poultices  be  used,  those  of  charcoal,  and  yeast 
with  nitric  acid,  are  the  best.  The  usual  means  adopted  to  prevent 
the  spread  of  mortification  must  be  had  resort  to  in  this  case,  such 
as  the  application  of  nitric  acid,  pure  carbolic  acid,  and  the  actual 
cautery. 

Diphtheritic  Vulvitis. — Whitridge  Williams,  in  drawing  attention  to  the 
presence  of  diphtheritic  vaginitis  or  endometritis,  has  shown  how  rarely  in 
these  cases  the  peculiar  greyish  white  membranes  formed  on  the  inner 
surface  of  the  labia  contain  the  typical  Klebs-Loffler  bacillus.  Such  mem- 
branes are  more  frequently  due  to  streptococci.  Antitoxin  and  local 
germicides  are  indicated  as  the  special  treatment. 

Warts  and  Vegetations. — These  growths  occur  in  difierent 
situations  around  the  vulvar  orifice.  They  are  frequently  the  result 
of  gonorrhcea  or  syphilis.  This,  however,  is  by  no  means  the  rule. 
I  have  seen  in  a  virgin,  suffering  from  leucorrhceal  discharge,  two 
fairly  large  vegetations  growing  from  the  neighbourhood  of  the 
clitoris. 

Treatment.  —  The   growths   are   removed   by    the   scissors   and 


828 


DISEASES   OF    WOMEN. 


galvano-cautery.     If  the  wart  be  of  large  size,  a  ligature  is  applied 

to  its  base  or  pedicle  a  few 
,2^?^    ^         "  -  ^  days    before    removal.      "We 

''^~     -  '  '. .     '    ,  thus    avoid    the    chance    of 

hsemorrhage,  which  otherwise 
may  be  inconvenient.  Such 
warts  should  never  be  cut  off 
carelessly  without  means  at 
hand  to  restrain  the  bleeding 
that  may  follow.  I  have  de- 
stroyed these  vegetations 
without  any  cutting  opera- 
tion, by  means  of  the  re- 
peated and  careful  application 
of  acid  nitrate  of  mercury, 
chromic  acid,  or  glacial  acetic 
acid.     In  aggravated  cases  it 

may  be  necessary  to  apply  Paquelin's  cautery  after  the  removal  of 

the  srowth  with  a  cutting  instrument. 


Fig.  538. — Vegetation  of  the  Vi'lva. 
(Taenier.) 


Transplantation  Operation  for  Recurrent  Vegetations  of  tlie  Vulva. — Tn  a  case 
of  extensive  recurring  vegetations  of  the  vulva,  I  was  present  at  the  University 
Fraueu  Klinik  in  Berlin  when  Koblanck  cleanly  dissected  off  the  mass,  leaving 
a  large  raw  oval  surface,  some  three  and  a  lialf  inches  in  length,  and  close 
on  three  inches  wide.  As  it  was  impossible  to  cover  the  surface  by  adjust- 
ment of  the  edges,  a  long  incision  was  carried  from  the  pubes  to  the  spinous 
process  of  the  ileum,  the  skin  was  raised,  and  the  glands  and  subcutaneous 
tissue  were  carefully  dissected  out.  The  denuded  surface  was  contracted  by 
two  superimposed  layers  of  gut  sutures,  passed  deeply  and  superficially  through 
the  tissues,  the  raised  skin  was  then  glided  over  the  raw  surface,  fixed  there 
by  sutures,  and  the  margins  of  the  wound  in  the  groin  were  brought  together. 
A  small  drainage-tube  was  inserted.     The  patient  did  remarkably  well. 

Trachoma  Pudendorum. — Tarnovsky  has  described  a  true  trachoma 
of  the  labia.  The  disease  consists  in  the  aggregation  of  nodules  of 
a  greyish  or  yellowish  colour.  These  may  coalesce  and  form  an  oval 
patch,  the  epithelium  covering  of  which  thickens  and  becomes 
rough.  The  nodules  contain  micrococci  and  epithelial  cells.  This 
condition  is  more  likely  to  be  found  in  those  who  have  been  exposed 
to  gonorrhoeal  infection.  It  causes,  especially  with  warmth  at 
night,  intense  itching  of  the  vulva,  and  a  sense  of  heat. 

The  treatment  consists  in  superficial  scarification  of  the  tracho- 
matous patch,  and  the  use  of  such  lotions  as  those  of  perchloride  of 


AFFECTIONS   OF   THE    VULVA.  829 

uierouiy  (1  in  2000),  nitrate  of  silver  (5 — 10  gr.  to  "^i),  or  chromic 
acid  (10  gr.  to  ^^i.). 

Cysts  of  the  Labia. — Cysts  of  the  labia  are  not  frequently  met 
with,  if  we  exclude  cysts  of  the  vulvo-vaginal  gland.  In  dealing 
with  a  cyst,  the  plan  is  not  difterent  to  that  which  we  pursue  in 
the  case  of  the  vulvo-vaginal  variety.  After  thorough  asepsis  of 
the  parts  has  been  secured,  and  the  tumour  has  been  made  tense 
by  pressure,  an  incision  is  carried  through  the  skin  surface  over 
the  whole  length  of  the  tumour,  down  to  its  wall.  This  having 
been  carefully  exposed,  the  dissection  is  carried  close  to  it  with  a 
blunt-pointed  bistoury,  a  flat  curved  scissors,  aided  by  the  handle 
of  the  knife  or  finger,  and  the  cyst  is  thus  carefully  isolated,  great 
care  being  taken  not  to  rupture  it.  This  is  certain  to  be  done  if  the 
point  of  the  knife  be  directed  to  the  sac,  or  if  it  be  grasped  roughly 
with  forceps.  Both  time  and  patience  are  required  to  effect  this 
little  operation  neatly,  and  withijut  the  risk  of  subsequent  hsemor- 
rhage.    (See  also  Hydrocele  of  the  Round  Ligament,  pp.  20  and  833.) 

Blood  Cyst  of  the  Labium. — A  single  woman  had  a  small  cystic  tumour  in 
the  riglit  labium,  about  tlie  size  of  a  large  hazel  nut.  It  had  commenced  to 
give  her  some  pain  and  distress.  I  exth'pated  it  intact,  and  on  opening  it 
found  that  the  contents  were  pure  blood.  It  was  the  only  blood  cyst  of  the 
kind  I  have  ever  met  with. 

Haematoma  after  removal  of  a  Cyst  of  the  Labium. — Some  years  since  I 
dissected  out  a  large  vulvo-vaginal  cyst,  which  had  assumed  the  size  of  a 
pigeon's  egg.  I  left  the  patient,  as  I  thought,  securely  protected  from  all  risk 
of  hsemorrhage.  I  was,  however,  called  at  night,  as  a  large  hsematomatous 
tumour  had  formed  in  the  vulva,  and  there  had  been  considerable  bleeding 
through  the  bandages.  In  this  case  I  had  to  turn  out  the  clots  which  filled 
the  cavity,  and  secure  the  bleeding-points  with  ligatures.    The  patient  did  well. 

In  all  operations  of  this  nature,  I  prefer  a  general  anaesthetic  to 
cocaine.  If  the  cyst  have  suppurated,  it  may  be  best  to  evacuate  the 
contents  by  running  a  bistoury  through  the  entire  length  of  the  sac 
wall,  clearing  out  the  cavity  well.  Having  scraped  the  internal 
surface,  it  is  wiped  dry,  and  then  mopped  out  with  either  strong 
iodine  or  formalin  solution,  after  which  it  is  filled  with  a  strip  of 
iodoform  gauze,  and  this  packing  is  repeated  while  there  is  any 
suppuration,  and  until  the  cavity  has  finally  granulated.  In  all 
instances,  however,  when  feasible,  extirpation  of  the  cyst  is  the 
proper  plan  to  adopt. 

Varix  of  the  pudendal  veins  is  generally  the  result  of  pregnancy. 
The  danger  is  rupture  of  a  vessel  and  serious  htemorrhage.  A 
suitable   air-pad  support  will   be  found  useful  in  these  cases.     If 


830  DISEASES   OF   WOMEN. 

haemorrliage  should  occur,  the  usual  means  must  he  taken  to 
control  it. 

Pudendal  Hsematoma  (wrongly  callerl  thrombus). — Blood  may 
pour  in  quantity  from  the  labia  in  consequence  of  puncture  or 
laceration  of  the  veins  of  the  vestibule,  or  it  may  accumulate  in 
the  cellular  tissue  of  the  labium.  This  accident  is  one  which  may 
occur  during  parturition.  Independently  of  pregnancy,  it  may 
follow  from  traumatic  causes  or  violent  muscular  efforts.  The 
sudden  appearance  of  a  swelling  in  either  labium,  following  the 
injury  or  strain,  and  the  sense  of  throbbing  and  pain  which 
generally  succeeds,  are  in  themselves  sufficient  to  indicate  the 
nature  of  the  accident.  However,  cases  occur  in  which  attention 
is  first  attracted  by  the  presence  of  a  tumour,  and  the  obstruction 
it  causes  to  micturition  or  coitus. 

Treatment. — If  the  vulva  be  bleeding  from  a  wound,  a  tampon 
must  be  placed  in  the  vagina,  and  a  firm  compress  with  a  T-bandage 
secured  externally.  This  should  include  a  small  ice-bag.  A  saturated 
solution  of  alum  may  be  kept  to  the  bleeding  part,  or  adrenalin  or 
renaglandin  applied.  An  acupressure  pin,  or  a  silver  suture,  can 
be  passed  from  the  cutaneous  to  the  mucous  surface,  so  as  to  com- 
press the  bleeding  vessel  (Goodell).  If  a  hfematoma  should  form 
after  the  removal  of  a  cyst  from  the  vulva  from  secondary  haemor- 
rhage, the  sutures  should  be  at  once  removed,  the  clots  turned  out, 
and  the  bleeding  points  secured  by  forcipressure  and  gut  ligature. 
When  from  other  causes  blood  is  effused  into  the  cellular  tissue, 
and  a  tumour  forms  in  the  labium,  it  may  be  absorbed,  remain  in 
a  liquid  state,  or  suppuration  may  occur.  Rest,  pressure,  and  the 
application  of  ice  will  generally  favour  absorption.  Should  this  not 
happen,  and  inflammation  and  suppuration  follow,  the  pus  must  be 
evacuated,  and  any  coagula  removed  by  an  incision  made  from  the 
mucous  surface  with  every  antiseptic  precaution. 

Lymphang-iectasis  of  the  Vulva. — Duvet  *  reported  a  case  of  this  affectioa  in 
a  patient  aged  17,  who  had  suffered  from  plilegmonous  oedema  of  the  vulva. 
Incisions  revealed  obstruction  of  the  lymph  channels,  and  were  followed  by 
lymphorrhagia  and  infection.  From  this  case  Duret  argues  that  tlie  presence 
of  filaria  is  not  necessary  for  the  occurrence  of  the  affection,  as  an  adeno- 
lymphangitis  caused  by  the  streptococcus  will  produce  dilatation  of  the  lymph 
glands,  leading  to  lymphorrhagia  with  its  consequences. 

Elephantiasis. — This  disease  i^arely  occurs  in  Europe.  The 
growth  is   a   chronic  hyperplasia  of  the  skin  and    cellular  tissue, 

*  Jour.  Sci.  Med:  Lille,  1902. 


AFFKCT/ONS   OF   THE    VULVA. 


831 


consequent  upon  an   inflammable   cedema,   which   is   characteristic. 
Ultimately   a   nooplastir    growth    forms,    which    is    developed    into 


Fig.  539. — Elephantiasis  VrLV^— Eight  Labium.     (From  PnoTOGiiArH 

TAKEN   BY   THE   AUTHOK    IlSf   SaXGEK'S   KlINIK,   PkAGXTE.) 

This  was  a  case  of  elephantiasis  of  the  right  labium,  in  a  patient,  aged  42,  who 
had  borne  three  children.  Five  years  before  the  growth  was  removed  slie 
liad  noticed  a  wart  on  the  right  labium  majus,  which  gradually  developed 
into  a  large  nodular  tumour,  which  is  shown  in  the  photograph.  It  finally 
involved  the  entire  extent  of  both  labia,  growing  to  the  size  of  a  ciiild's 
head.     It  was  removed,  and  recovery  was  perfect. 


Fig.  540.— ELEPHAXTiA.>iri  Vulvjd.    (Hallidat  Groom.) 
The  measurements  under  anresthesia  were— antero-posterior,  12  ins. ;    lateral, 
6  ins. ;  vertical,  6  ins.     The  tumour  was  successfully  removed,  and  the  cure 
has  been  comi^lete. 

fibrous  tissue.     The  surface  of  the  skin  finally  becomes  thick  and 
scaly,  from  changes  in  its  papillary  and  epidermic  layers.    A  section 


832 


DISEASES   OF   WOMEN. 


of  the  aiiected  skin  is  made  up  of  massive  fibrous  bands  of  white 
and  elastic  tissue,  with  cedematous,  connective,  and  adipose  tissue, 
while  the  lymph  spaces  are  enlarged  and  the  lymphatics  are  dilated 
and  varicose,  consequent  upon  the  absorption  of  the  lymphatics 
(Pye  Smith). 

These  changes  are  frequently  associated  with  the  presence  of  the 
parasite  Filaria  sanguinis  (Filaria  Bancrofii). 

Labourand  has  drawn  attention  to  the  attacks  of  lymphangitis  and  fever 
which  periodically  occur  during  the  invasion  of  the  connective  tissue  and 
lymph  spaces  by  microbes  (streptococcus  of  Fehleisen),  associating  it  with  the 
lymphangitis  of  syphilis.  This  indicates  the  importance  of  asepsis  in  the 
treatment  of  the  disease. 

Appearance,  Symptoms,  and  Diagnosis.  —  The  characteristic 
swelling  and  thickness  of  the  skin  over  the  perineum  and  vulva, 

with  the  large  tumours  that  sub- 
sequently are  formed,  afford  suffi- 
cient evidence  of  the  nature  of  the 
disease.  The  friction  of  the  op- 
posite lips  may  lead  to  ulceration, 
and  occasionally  vegetations  are 
found,  due  to  papillary  hyper- 
trophy. The  tumid  jDarts  may  be 
attacked  with  erysipelas,  when 
there  will  be  the  usual  symptoms 
of  this  affection.* 

Treatment. — The  sole  treatment 
is  ablation,  in  which  special  atten- 
tion has  to  be  paid  to  the  control 
of  haemorrhage.  In  the  female, 
the  elastic  ligature  and  clamp  may 
be' availed  of.  The  galvano-cautery 
loop  can  also  be  used.  Every  care 
must  be  taken  to  prevent  sepsis  or  suppuration.  The  earlier  an 
operation  is  performed  the  better,  unless  it  be  contra-indicated  by 
such  conditions  as  albuminuria,  angemia,  dysentery,  or  tumours  of 
the  uterus. 

Tumours  of  the  Vulva,  sarcomatous,  carcinomatous,  fibromatous, 
and  lipomatOUS,  are  found  growing  from  the  labium,  nymphse, 
hymen,  and  clitoris.  Such  growths  have  to  be  freely  ablated. 
Perhaps   the  most  commonly  met  with   are  the  lipomata.      They 

*  See  Tumours  of  the  Vagina,  pp.  863,  864. 


/ 


Fig. 


541. — Elephantiasis  Vulv^. 
(Pozzi.) 


AFFECTIONS   OF   THE    VUf.VA.  833 

present  the  usual  characters  of  lipoma  elsewhere.  If  small,  they 
might  be  mistaken  for  hernia,  but  they  are  not  reducible.  They 
are  round  in  shape,  somewhat  soft,  and  gi\e  a  sense  of  fluctuation. 
They  are  frequently  pediculated.  There  is  no  difficulty  in  their 
removal.  Should  they  involve  the  inguinal,  and  extend  into  the 
vaginal  canal,  they  must  be  carefully  enucleated,  and  bleeding 
checked  by  forcipressure. 

Hernia  of  either  the  ovary  or  intestine  may  occur  into  the 
labium.'''  Its  descent  by  the  unobliterated  canal  of  Nuck  is  analo- 
gous to  the  corresponding  descent  of  the  intestine  in  inguinal  hernia 
in  the  male.  The  bowel,  if  not  strangulated,  can  generally  be 
reduced  in  the  recumbent  posture  by  taxis.  The  possibility  of  this 
accident  must  be  remembered  by  the  surgeon  before  he  proceeds 
to  open  an  assumed  abscess  or  cyst  of  the  labium.  Cysts  of  the 
round  ligament  are  liable  to  be  mistaken  for  hernia.  These  cysts 
may  be  due  either  to  effusion  of  blood  in  unobliterated  canals  in 
the  ligament,  or  to  distension  of  the  vaginal  process  of  the  peri- 
toneum, the  inguinal  portion  being  obliterated.  Such  cysts  are  apt 
also  to  be  mistaken  for  cystic  distension  of  the  vulvo-vaginal  gland. f 

Hydrocele,  or  an  accumulation  of  fluid  in  the  canal  of  Nuck,  is  of 
rare  occurrence.  It  may  be  sacculated  if  the  abdominal  opening  of 
the  canal  be  closed,  otherwise  the  fluid  can  be  pressed  out  of  the 
sac.  The  error  of  mistaking  it  for  hernia,  tumour,  or  abscess  has 
not  infrequently  been  made. 

Hydrocele  of  the  processus  vaginalis  may  appear  as  a  cyst  of  the 
round  ligament,  and  be  confounded  with  true  peritoneal  hydrocele. 
It  also  may  cursorily  be  mistaken  for  an  inguinal  hernia.  Other 
tumours  of  the  round  ligaments  occur,  either  independently  of,  or 
associated  with,  inguinal  hernia.  These  tumours  develop  in  the 
inguinal  canal,  and  are  of  a  myomatous  or  myo-sarcomatous  nature. 
Howard  Kelly  has  recorded  an  interesting  case  of  pseudo-myxoma 
consequent  upon  rupture  of  an  ovarian  cyst,  and  also  a  myoma  of 
the  round  ligament. 

Already  \  the  possibility  has  been  referred  to  of  confusing  hernia 
with  hydrocele  of  the  round  ligament,  and  a  case  instanced  in 
which  this  occui'red.  I  also  pointed  out  the  structures  in  the 
round  ligament,  which  explain  the  occurrence  of  hernia  or  cysts  in 
connection  with  it  (p.  20).  By  these  anatomical  data  we  can  explain 
the  presence  of  intestinal  hernia,  epiplocele,  hydrocele,  incarcerated 

*  See  Salpingocele,  p.  682.  f  See  Vaginal  C'j'sta. 

$  Sec  pp.  3  and  20. 

3    H 


834  DISEASES   OF    WOMEN. 


ovary,  and  a  cyst  or  fibroma  in  the  canal  and  labium.  The  diagnosis 
is,  as  in  the  cases  recorded  by  me,*  not  always  easy.  Pozzi,  in 
speaking  of  the  fluid  contained  in  cysts  in  the  canal,  says  that  the 
persistence  of  the  canal  of  Nuck  is  looked  upon  by  most  authorities 
as  explaining  the  presence  of  such  cysts,  though  this  is  denied  by 
Duplay,  and  Schroeder  has  reported  a  case  in  which  he  was  able  to 
return  the  fluid  into  the  abdomen,  thus  demonstrating  a  communi- 
cation of  the  cyst  with  the  peritoneal  cavity,  and  establishing  a 
resemblance  to  congenital  hernia  in  the  male.  As  will  be  seen,  this 
is  exactly  what  occurred  in  one  case.  Sometimes  the  cyst  may 
be  seated  in  the  interior  of  the  round  ligament.  This  may  be  due 
(Weber)  to  a  persistence  of  the  female  gubernaculum  in  its  foetal 
form. 

Cysts  of  the  Round  Ligament. 
A  woman,  aged  26,  unmarried,  consulted  me  for  a  swelling  in  the 
right  groin.  This  she  first  noticed  some  months  previously  ;  it  gave 
her  little  pain,  but  it  varied  in  size.  On  examination  I  found  a 
swelling  in  the  right  inguinal  region,  extending  almost  into  the 
labium.  There  was  an  impulse  on  coughing,  and  by  steady  pressure 
in  the  horizontal  position  the  swelling  was  reduced  and  practically 
disappeared.  This  collapse  of  the  tumour  puzzled  me,  as  I  had 
rather  inclined  to  the  view  that  I  was  dealing  with  a  hydrocele  of 
the  round  ligament.  It  was  not  possible  for  her  to  undergo  an 
operation  at  the  time,  so  I  devised  a  special  horseshoe  air-pad  truss 
to  be  worn  over  the  abdominal  ring.  This  she  wore  for  several 
months,  when  I  again  saw  her,  and  then  I  found  that  the  swelling 
had  practically  disappeared.  I  advised  that  she  should  still  wear 
the  truss.  Shortly  after  this  she  had  serious  domestic  trouble,  and 
lost  flesh.  The  truss  slipped  up  from  the  position  I  had  intended 
it  to  be  worn  in,  and  the  swelling  reappeared  again,  and  now 
gradually  increased  to  the  size  of  a  large  pigeon's  egg.  When  I 
next  saw  her  I  found  this  swelling  was  tense,  partly  occupied  the 
labium  ma  jus,  and  was  not  now  influenced  by  pressure.  I  advised 
operation.  On  dissecting  down  to  the  surface  of  the  sac,  this  was 
seen  to  be  of  a  deep  blue  colour.  The  wall  consisted  of  a  thin 
membrane,  and  was  covered  with  vessels.  It  had  much  the  appear- 
ance of  the  wall  of  a  hernial  sac.  On  opening  it,  fluid  blood  escaped. 
The  sac  was  attached  to  the  round  ligameiit,  and  had  formed  adhe- 
sions in  the  canal  up  to  the  internal  abdominal  ring.  I  dissected 
*  Brit.  Gyn.  Soe.,  May,  1903. 


AFFECTIONS  OF   THE    VULVA.  835 

out  the  sac  and  explored  the  internal  ring,  which  I  found  empty. 
It  was  clear  that  the  canal  of  Nuck  was  patent,  and  that  the  cyst 
was  a  hydrocele,  into  which  the  blood  had  escaped.  The  round 
ligament  was  drawn  forwards  and  fixed  at  the  internal  ring,  which 
was  then  closed,  and  the  canal  itself  was  obliterated  by  a  series  of 
cross  sutures  which  included  the  round  ligament.  The  wound 
healed  aseptically. 

In  the  second  case,  a  lady  sutfered  from  disease  <jf  the  adnexa 
and  incontinence  of  urine  due  to  exaggerated  anteflexion  of  a  hyper- 
trophic uterus  ;  there  was  also  what  I  believed  to  be  an  irreducible 
hernia,  though  with  the  experience  of  the  last  case  before  me  a 
qualified  diagnosis  was  given.  Here  also  the  tumour  varied  con- 
siderably in  size.  After  the  operations  of  salpingo-oophorectomy 
and  fijxation-  of  the  uterus  were  completed,  and  the  abdominal  wound 
was  closed,  I  opened  the  inguinal  canal  and  found  an  isolated  cyst, 
about  the  size  of  a  small  walnut,  on  which  the  round  ligament  was 
spread,  and  to  which  it  was  attached.  There  was  no  funicular 
process  of  peritoneum  as  in  the  last  case,  the  internal  ring  and  the 
parts  above  the  cyst  being  normal  in  their  appearance  and  relations. 
The  cyst  was  dissected  out  and  the  canal  closed  in  the  same  manner. 
Recovery  was  perfect. 

"We  have  here  examples  of  two  distinct  types  of  round  ligament 
cysts  ;  the  one  obviously  the  consequence  of  a  permanent  canal  of 
Nuck  and  connected  with  the  persistent  peritoneal  process,  for  when 
I  first  saw  the  patient  the  fluid  was  evidently  returnable  into  the 
peritoneal  cavity.  The  other  cyst  originated  most  probably  in  the 
areolar  tissue  in  the  round  ligament,  or  possibly  from  a  persistent 
embryonic  gubernaculum.  Either  of  these  forms  of  cyst  of  the 
round  ligament  is  liable  to  be  mistaken  for  hernia,  or  the  latter, 
possibly,  for  an  incarcerated  ovary  ;  a  more  serious  error,  as  in  the 
first  case  I  related,  is  that  hernia  may  be  mistaken  for  a  cyst  or  a 
hydrocele.  Under  any  circumstances,  the  safe  rule  for  every 
dubious  swelling  in  the  inguino-labial  region  in  a  woman  is  to 
operate. 


Epithelioma  and  Chancroid. 

In  the  diflerentiation  of  epithelioma  of  the  vulva  from  chancroid,  the 
following  tabular  composition  of  the  two  diseases  is  useftd.  It  has  been 
drawn  up  by  Davis  of  Atlanta. 


836 


DISEASES  OF   WOMEN. 


Epithelioma. 

Age. — Usually  occurs  later  in  life, 
after  35  years.  There  are  cases  re- 
corded as  occurring  before  20  years 
of  age.     These  are  rare. 

Heredity.  —  History  of  malignant 
disease  of  ancestors. 

Location. — When  confined  to  cer- 
vix, most  frequently  found  at  the  site 
of  a  previous  laceration. 

Frequency.  —  Not  of  rare  occur- 
rence. Married  women  and  those 
having  borne  children  suffer  oftenest. 

Development. — Usually  slow  at  first. 
Begins  as  a  hard  elevation  or  nodule. 

Number. — At  first  a  simple  ulcer, 
until  the  glandular  tissue  breaks 
down,  forming  another. 

Auto-inoculation. — Questionable. 

Colour.  —  Dirty,  with  livid  edges 
covered  over  with  broken-down  tissue. 
Discharges  a  foetid  ichorous  fluid, 
very  irritating. 

Hydrorrhoea  and  Haemorrliage. — No 
tendency  to  cicatrization.  Extends 
in  direction  of  vagina  and  uterus. 

Buboes. — Late.  Multiple  enlarge- 
ment of  glands. 

Microscope. — Shows  presence  of 
epithelial  scales  in  so-called  nests. 

Cachexia. — Marked — in  the  later 
stages  of  the  disease. 


Chancroid 

Occurs  usually  early,  but  may  be 
observed  in  the  old. 


Plays  no  part. 

On  lov/er  fourth  of  vagina,  and 
sometimes  on  cervix. 

Eare.  Prostitutes,  or  married  women 
who  become  infected  by  their  hus- 
bands, are  affected. 

Rapid.  Begins  as  a  pustule, 
rapidly  becoming  an  ulcer. 

May  be  single  at  first,  but  rapidly 
becomes  multiple. 

Auto-inoculable,  producing  charac- 
teristic chancroid. 

Yellow,  tawny,  and  discharging  a 
yellow  pus. 


No  hydrorrhcea ;  little  heemor- 
rhage.  Evidences  of  cicatrization  on 
vaginal  and  cervical  surface. 

Occur  early  and  suppurate,  as  a  rule. 
Usually  single. 

Absence  of  these. 

Usually  absent. 


Solid  Tumours.* 

Fibromyoma,  myxoma,  lipoma,  sarcoma,  tubercle,  papilloma,  con- 
dyloma, molluscum,  polypus,  may  occur  in  the  vulva. 

Enormous  pendulous  tumours  have  been  recorded  as  growing  from  the 
vulva,  such  &?,  encapsulated  fihromyoma  (Reverdin),  molluscum  2^endulum, 
pediculated  polypus  (Moclaire).  One  of  the  latter  reached  as  far  as  the 
inner  condyle  of  the  femur,  thirteen  inches  in  length.  In  its  point  of  greatest 
diameter  it  measured  twenty-five  inches.  Large  pediculated  myxomatous 
tumours  have  been  recorded  (Kortright). 

Lupus  and  Tubercle. — See  chapter  on  Tubercle. 

*  See  Tumours  of  the  Vagina  and  Clitoris. 


CHAPTER    XLIII. 


AFFECTIONS    OF   THE    VAGINA. 


Vaginismus. 
Vaginitis. 

simple, 
follicular, 
granular, 
gonorrhceal. 
diphtheritic. 
Malformation. 
Atresia. 

Partial — Congenital     and 

acquired. 
Complete — Congenital    and 
acquired. 
Injuries  resulting   in   cicatricial 
contractions  and  adhesions. 
Syphilis. 
Prolapse. 
Tuberculosis. 
Cancer. 
Cysts. 


Fibromyoma. 

Myoma. 

Lipoma. 

Adeno-fibroma. 

Foreign  bodies. 

Abscess   in  the   urethro-vaginal 

septum.* 
Varicocele    of  the   recto-vaginal 

septum,  t 
Ptuptui"e. 

Chorion-epithelioma. 
Fistulfe. 

,,       vesico-vaginal. 

„       urethro-vaginal. 

„       urethro-vesico-vaginal. 

,,       vesico-uterine. 

,,       recto- vaginal. 

, ,       perineo- vaginal . 

,,       peritoneo-vaginal. 


Vaginismus. — Vaginismus  is  one  of  those  terms  unfortunately 
employed  to  designate  a  disease,  when  it  should  only  be  used  as 
descriptive  of  a  symptom  that  may  be  due  to  several  morbid  or 
abnormal  conditions,  both  of  the  vulvar  orifice  and  vagina.  The 
spasm  attending  the  vaginismus  has  been  looked  on  as  a  '  neurosis 
of  motion '  (Matthews  Duncan).  There  can  be  no  doubt  that  we 
find  this  symptom  associated  with  morbid  apprehensiveness  of 
touch  or  intercourse  in  women  whom  we  describe  generally,  if 
somewhat  loosely,  as  '  neurotic,'  or  by  the  equally  vague  and  general 
term,  'hysterical."     '  Hyperesthesia  of  the  vulvar  outlet '' expresses 

*  See  chapter  on  the  Urethra.  f  See  chapter  on  the  Kectum. 


838  DISEASES   OF   WOMEN. 

the  condition  correctly.  The  muscles  said  to  be  principally  affected 
are  the  bulbo-cavernosi  and  the  levator  ani,  but  the  entire  muscular 
structure,  voluntary  and  involuntary,  including  frequently  the 
abductors  of  the  thigh  and  the  glutei,  are  occasionally  involved  in 
the  spasm.  There  is  a  state  of  extreme  irritability  of  the  nerves 
supplying  the  vulvar  orifice  and  the  vagina,  and  this  irritability  is 
often  associated  with  a  vascularity  of  the  vestibule,  and  a  condition 
that  Tait  described  as  '  serpiginous  vascular  degeneration.' 

Causation. 

Hysteria. 

Vulvar  hypersesthesia  (Tillaux). 

Slight  ulceration  of  the  vulvar  orifice. 

Serpiginous  vascular  degeneration  of  the  vestibule  (Tait). 

Fissures. 

Disproportion  between  the  size  of  the  vaginal  orifice  and  the 

male  organ. 
Caruncle  of  the  urethra. 
Chronic  vaginitis. 
Chronic  endometritis. 
Coccygodinia. 
Masturbation. 
Incomplete  intercourse. 
Uterine  inflammatory  states  and  morbid  discharges. 

It  is  frequently  associated  with  a  disorder  of  menstruation. 

Hilton  and  More  Madden  dwelt  on  the  nerve  supply  of  the 
sphincters  (vaginal,  rectal,  urethral),  and  the  part  played  by  the 
common  innervation  of  these  orifices.  It  is  urged  that  in  vagi- 
nismus the  lesion  in  the  sensitive^  filaments  of  the  internal  pudic 
nerve,  distributed  to  the  vulva,  vagina,  and  anus,  is  the  cause  of 
the  reflex  spasm  and  pain.  There  is  an  important  anatomical 
defect,  to  which  Hegar  and  Kaltenbach  have  drawn  attention,  that 
in  itself  may  cause  ineffectual  intercourse,  viz.  the  position  of  the 
vaginal  orifice,  whicll  is  placed  too  far  forwards  in  consequence  of 
too  great  pelvic  obliquity.  In  some  women  the  clitoiis,  also,  is 
abnormally  placed,  and,  lying  more  in  front,  there  is  not  the  same 
natural  sexual  gratification  as  when  it  is  in  the  normal  position. 
Such  women  complain  that  intercourse  has  little  or  no  pleasurable 
effect.     Yet  they  often  conceive  and  bear  children. 

The  cases  are  frequent  in  which  coitus  is  prevented  through  a 


AFFECTIONS   OF   THE    VAGINA.  839 


vaginitis  that  commences  shortly  after  marriage  from  incomplete 
and  repeated  efforts  on  the  part  of  the  husband.  This  may  be  due 
to  rigidity  of  the  hymen,  a  contracted  outlet,  or  some  previous 
sensitiveness,  consequent  upon  an  old  leucorrh(pa  and  slight  cervical 
erosion  that  has  passed  unnoticed.  A  muco-puriilent  discharge 
commences,  the  vulva  is  swollen,  or  small  erosions  appear  on  the 
lips,  and  the  follicles  stand  out  as  little  purulent  points  on  tlie 
mucous  surfaces.  Here  intercourse  is  impossible,  or  only  completed 
with  great  pain.  The  woman's  health  of  mind  and  body  suffers, 
and  the  happiness  of  married  life  is  interrupted. 

I  have  treated  many  such  cases,  in  some  of  which  coitus  had  to  be 
abandoned  for  as  long  as  two  or  three  years  after  marriage.  The  uterus  in 
one  case  was  tented  and  superficially  curetted ;  an  erosion  of  the  cervix  was 
cured  by  nitric  acid  application ;  the  aphthous  and  eroded  spots  on  the  vulva 
and  about  the  urethra  were  touched  with  carbolic  acid,  and  vaginal  glass 
dilators  were  used  both  to  keep  the  vagina  dUated  and  as  rests.  Within  two 
months  from  the  commencement  of  the  treatment  the  patient  was  pregnant. 

Impotence  in  the  Husband  a  Cause. — A  patient  consulted  me,  some  years  since, 
and  gave  the  following  history.  She  had  married  six  months  p^eviousl3^  Her 
husband  had  never  had  a  complete  erection.  This  led  to  frequently  repeated 
and  futile  attempts  at  intercourse.  Of  late  any  attempt  at  this  produced  great 
pain.  On  examination  I  found  a  catarrhal  discharge  pouring  from  the  highly 
irritable  and  vascular  vulva.  The  general  health  had  also  deteriorated.  On 
further  inquiry  I  detected  in  the  husband  a  spinal  lesion,  which  explained  the 
impotence.  This  is  but  an  example  of  similar  cases  that  not  infrequently  seek 
advice,  in  which  ineffectual  and  awkward'  coitus  has  gradually  produced 
hypersesthesia  and  irritability  of  the  vulva  muscles.  The  same  general  con- 
dition may  follow  upon  intentional  suppression  of  emission  in  order  to  prevent 
conception.* 

Symptoms  and  Physical  Signs. — ^The  slightest  touch,  even  with  a 
feather,  of  the  mucous  membrane  of  the  vulva,  causes,  in  aggravated 
cases,  pain  and  spasm.  Examination  with  the  finger  without 
cocaine  or  an  anaesthetic  is  impossible.  Sexual  intercourse,  at  first 
painful,  becomes  ultimately  intolerable,  and  all  sexual  desire  is  lost. 

On  examination  of  the  external  genitals  we  may  discover  in  some 
exquisitely  sensitive  spot  the  source  of  the  pain  and  dyspareunia. 
The  margins  of  the  hymen  in  married  women  may  be  hypertrophied. 
We  may  detect  a  fissure  at  the  fourchette,  some  small  ulcers  about 
the  hymen  or  near  the  urethral  oriBce,  or  an  irritable  caruncle  of  the 
urethra  and  general  vascularity  of  the  vulvar  orifice.  In  any  case 
of  vaginismus  where  we  cannot  discover  a  local  cause  for  the  spasm 
in  the  vulva  or  vagina,  a  careful  exploration  of  the  rectum  should 
*  See  chapter  on  Sterility. 


840 


DISEASES   OF    WOMEX. 


be  made.  In  many  cases  there  is  rigidity  of  the  sphincter  ani. 
This  chronic  condition  of  rectal  spasm,  Sims  says,  is  pathognomonic. 
We  may  find  the  source  of  the  affection  in  some  ulcer,  fissure,  or 
ha3morrhoidal  state  of  the  rectum  or  anus.  In  connection  with  this 
fact,  it  must  be  remembered  that  excessive  sexual  indulgence  may 
predispose  to  a  hsemorrhoidal  condition  of  the  rectum. 

Diagnosis. — This  is  easily  made,  and  the  history  of  the  case  is  of 
itself  sufiicient  to  indicate  the  affection. 

Treatment  may  be  divided  into  general  and  local. 

The  General  Treatment  consists  of — 
Avoidance  of  intercourse. 
Change  of  air. 
Seabathing. 
Warm  alkaline  baths  of  bicarbonate  or  salicylate  of  soda  and 

starch,  using  a  bath  speculum  in  the  vagina. 
Exercise.     (Especially  horse  exercise.) 
Avoidance  of  a  too  stimulating  diet. 

Administration  of  Tonics  : 
Bromides,  with  valerian. 
Bromide  and  valerianate  of  zinc. 


Suppositories — 

Cocaine  (gr.  ii.). 
Morphia  (gr.  i.). 
Belladonna  ext.  (gr.  ii.). 
Iodoform  (gr.  v.). 
Hyoscyamusext.  (gr.  x.). 


Local  treatment  : 
Warm  vaginal  washes  of — 

Bicarbonate  with  salicylate  of  soda. 
Borate  of  soda. 
Glycothymolin  or  formolyptol. 
Perchloride  of  mercury  (1  in  5000). 
Laudanum  (^i.  in  Oi. ). 
Chloral  (gr.  xx. — xxx.  in  Oi.). 
Solution  of  subacetate  of  lead  (ji.  in 

Oil.). 
Tincture  of  calendula  (^ss-  in  o^-)- 

Lanolated  Creams  of — 
Cocaine  (2-4  per  cent.). 
Belladonna  Extract  (gr.  x.  ad  ji-)- 
Morphia  (gr.  v.  ad.  ^i-)- 
Atropia  (gr.  ii.  ad.  Ji.). 

Iodoform  disguised  with  coumarin  (gr.  xx. — 5iv.). 
Vasol  Iodine  — Ichthyol. 


A  vaginal  dilator  or  rest  may  be  worn  at  night,  and  also  for  some 


AFFECTIONS   OF  THE    VAGINA. 


841 


time  in  the  day.     It  can  be  retained  in  its  place  by  a  perineal 
bandage. 
Medicated  glycerine  tampons,  with  chloi-al  and  cocaine  or  ichthyol, 
may  be  worn  at  night. 


Fig.  51:2. — Solid  Glass  Dilator  and  Eest  of  Author. 

Made  in  four  sizes.     I  find  these  far  more  effectual  than  the  light,  hollow 
rest  of  Sims. 

The  warm  vaginal  douche  may  be  used  night  and  morning,  with 

alkaline,  sedative,  or  astringent  lotions  added. 
Applications — 

Cocaine  (5-10  per  cent.). 

Solution  of  nitrate  of  silver  (gr.  xx.  ad  ji.)  applied  to  the  vaginal 

walls. 
The   fused    stick  of   nitrate  of  silver  lightly  touched  to  the 

eroded  or  sensitive  parts. 
Carbolic  acid,  used  in  the  same  way. 
Operative  Measures. — To  dilate  the  vagina,  a  diverging  and 
conical  Cusco's  bivalve  vaginal  speculum  with  obturator  may  be 
used.  The  patient  having  been  anaesthetized,  the  vulvar  orifice  is 
dilated  with  the  thumbs,  and  the  speculum  is  inserted.  I  prefer  my 
solid  glass  dilator.  It  is  left  in  the  vagina  for  some  hours  after  it 
has  been  first  passed.  For  a  few  days  subsequently  the  dilator  can 
be  gently  introduced,  and  retained  in  position  with  a  T -bandage 
for  an  hour  or  more.  The  patient  can  then  pass  it  herself  daily, 
and  can  keep  it  for  a  short  time  in  its  position  with  a  diaper 
(Fig.  542J. 

Sims'  operation  consists  in  ablation  of  the  hymen  and  incision  of  the  perineal 
body.  The  first  step  of  the  operation  is  performed  with  a  curved  scissors ;  the 
second  with  a  scalpel,  two  incisions  being  made  through  the  vaginal  tissue, 
one  at  either  side  of  the  mesial  line  of  the  perineum,  both  meeting  in  the 
raphe,  '  Each  cut  will  be  about  two  inches  long,  i.e.  half  an  inch  or  more  above 
the  edge  of  the  sphincter,  half  an  inch  over  its  fibres,  and  an  inch  from  its  lower 
edge  to  the  perineal  raphe.' 

This  procedure  will  seldom  be  found  necessary  if  the  other  means 
of    treatment  be  carefully  carried  out,  especially   removal   of  the 


842 


DISEASES   OF   WOMEN. 


hypertrophied  portions  of  hymen  and  systematic  dilatation  of  the 
vagina. 

More  Madden  advocates  Emmet's  modification  of  Sims'  operation — ^by  means 
of  the  finger  within  tlie  anus.  The  sphincter  ani  is  pressed  against  the  posterior 
wall  of  the  vagina,  and  Avith  a  scissors  the  fibres  encircling  the  vagina  on 
each  side  are  freely  divided  under  the  mucous  membrane. 

Obviously,  all  special  applications  will  fail  if  we  do  not  recognize 
and  treat  any  diseased  condition  of  uterus,  vagina,  or  vulva 
which  causes  or  complicates  the  vaginismus.  The  state  of  the 
urine  must  be  carefully  inquired  into,  any  uterine  discharge 
attended  to,  any  vascular  urethral  growths  removed,  and  small 
ulcerations  and  fissure  of  the  vaginal  orifice  be  healed.  These 
cases  are  frequently  cured  by  parturition.  At  times  the  essentially 
neurotic  nature  of  the  complaint  is  shown  by  the  return  of  the 
symptoms  after  labour. 

To  show  the  importance  of  examining  the  urine  in  cases  of  vaginal  irritation, 
I  hereby  give  the  analysis  of  a  few  specimens  selected  from  cases  in  which  the 
irritation  was  unequivocally  due  to  the  urinary  secretion  : — 

Urine  of  Patients  suffering  from  Severe  Hyperaesthesia,  Pruritus  Vulvae, 
and  Slight  Vulvitus. 

No.  I.  was  pale  lemon-coloured,  turbid,  and  deposited  on  standing  a  mixed 
sediment. 

No.  II.  had  a  similar  colour,  but  was  more  tiuhid,  and  gave  a  larger  deposit 
on  standing  a  short  time. 

Their  analysis  gave  the  following  results 

Specific  gravity    .      .  . 
Eeaction 

Total  solids,  per  cent.  . 
„     urea,  per  cent.     . 
„     uric  acid,  per  cent. 
„     acidity,  per  cent. 
„     sugar,  per  cent. 

„     phosphoric  anhydride  as  phosphate 
„     chlorine  as  chlorides    . 
The  deposit  from   No.  I.  was   isolated,  and   tliere    were   rosette  prisms   of 
ammonio-magnesium  phosphate,  hexagons  of  uric  acid,  mucus,  epithelium,  and 
debris. 

The  deposit  from  No.  II.  was  ammonio-magnesium  phosphate,  calcium  phos- 
phate, octahedral  calcium  oxalate,  acicular  uric  acid,  a  few  globules  of  fat, 
mucus,  epithelium,  and  debris.  G-  B. 

Xo.  8. 

Specific  gravity '  •         ■  3026 

Reaction Acidulous. 

Total  solids,  per  cent.      .         .         .         .         .         .  6-11 

,,     urea,  per  cent.         ..'....  1'42 


Xo.  6. 

Xo.  7. 

.     1016 

1021 

Acid. 

Acid. 

3-70 

4'90 

1-14 

1-82 

0-05 

0-06 

0-42 

0-.39 

0-01 

0-005 

0-39 

0-36 

0-82 

0-6B 

AFFECTIONS   OF    THE    VAGTNA. 


84:5 


No.  8. 

Total  uric  acid,  per  cent.          .... 

n-08 

„     acidity,  per  cent 

()'87 

„     phosphoric  anhydride  as  phosplinte 

0-55 

„    clilorino  as  chlorides       .... 

0-54 

,»     snsar 

003 

,,     albumen  ....... 

.     A  faint  trace. 

This  '  oveninj? '  urine  was  excessively  acid  and  super-phosphatic. 

The  deposit  contained  was  octahedral,  and  dumb-bell  forms  of  calciimi  oxalate, 
splicroids  of  sodium  urate,  rhombs  of  calcium  pliosphato,  a  few  pus  <;;ranulcs, 
mucus,  epithelium,  and  urinary  d('bris. 


Urine  of  Patient  suffering  from  Follicular  Vulvitis. 

Urine  of  patient  suffering  from  chronic  and  recurrent  follicular  vulvitis,  with 
severe  irritation  and  pruritus  : — 

Reaction Acidulous. 

Specitie  gravity 1021 

Urea,  per  cent. Vl 

Sugar,  per  cent 025 

Albumen A  faint  trace. 

Acidity 0032 

The  deposit  contained  abundance  of  vesical  mucus  and  epithelium,  a  few  pus 
granules,  stellate  or  rosette  masses  of  the  acicular  crystals  of  uric  acid  coloured 
with  uroxanthin  and  fat  globules. 

The  albuminous  reaction  of  the  urine  may  have  originated  from  the  serum 
of  pus. 

The  sugar  was  estimated  volumetrically  by  Pavy's  ammoniacal  coiaper  test. 


Urine  of  Patient  suffering  from  Vaginal  Hypersesthesia  and  Irritation. 


Specific  gravity 

1027 

Reaction 

Acidulous 

Total  solids,  per  cent 

6-35 

„     urea,  per  cent 

2-40 

„    uric  acid,  per  cent.          .... 

0-10 

„    acidity,  per  cent 

117 

„     sugar,  per  cent 

003 

„    phosphoric  anhydride  as  phosphates 

-  0-89 

„     chlorine  as  chlorides       .... 

0-42 

The  deposit  consisted  of  sodium  and  ammonium  urates,  uric  acid,  ammonio- 
magnesium  phosphate,  mucus,  epithelium,  and  debris. 

A  highly  acid  and  superphosphatic  urine  loaded  witli  urates,  and  slowly 
changing  into  phosphates  and  free  uric  acid. 

Gaillard  Thomas  and  Sims  proposed  in  those  cases  where  the  marital  act  is 
impossible  from  the  attendant  pain,  to  anfcsthetize  the  woman  thoroughly,  in 
the  hope  that  complete  connection,  under  these  circumstances,  might  result 
in  pregnancy.  Mann,  objecting  to  this  suggestion,  says  that  even  if  pregnancy 
should  occur  in  such  cases  it  does  not  cure  the  vaginismus,  which  returns 
after  it  has  terminated. 


844  DISEASES    OF    WOMEN. 

Vaginitis. 

The  clinical  division  of  vaginitis  into  constitutional  and  local  is 
most  important  from  a  practical  point  of  view.  It  is  natural  that, 
in  the  anxiety  to  cure  this  troublesome  and  often  obstinate  local 
disorder,  the  constitutional  state  behind  it  should  occasionally  be 
overlooked.  We  are  not  infrequently  consulted  for  vaginitis  that 
has  resisted  active  local  treatment,  and  in  which  errors  of  diet  or 
a  disordered  condition  of  the  urinary  organs  have  explained  the 
obstinacy  of  the  inflammation.  The  rectification  of  the  constitu- 
tional error  has  been  the  first  step  towards  the  amelioration  of  the 
local  irritation. 

Varieties.^ — -Yasrinitis  is — 


Acute  or  Chronic. 


Simple. 
Cystic. 
Granular. 


Gonorrhojal. 
Diphtheritic. 
Adhesive. 


Simple  Acute  Vaginitis. 

Causation. ^ — In  practice  the  first  important  point  to  decide  is 
whether  the  vaginitis  be  a  primary  affection,  or  secondary  to 
(a)  any  constitutional  error,  (6)  some  local  disorder  in  the  uterus  or 
bladder. 

As  a  primary  affection  it  owes  its  origin  most  frequently  to — 

Exposure  to  cold. 

Traumatic  causes. 

Violent  coitus. 

Pessaries. 

Caustics  and  irritants. 

Pathology. — The  vaginal  mucous  membrane  passes  through  the 
ordinary  stages  of  inflammation  :  increased  vascularity,  congestion, 
and  swelling.  At  first  there  is  arrested,  and  secondarily  increased, 
secretion.  This  inflammatory  state  is  attended  by  desquamation  of 
the  epithelium,  and  the  presence  of  mucus  with  pus.  Frequently 
this  stripping  of  the  epithelium  leads,  from  the  irritation  of  accumu- 
lated acrid  discharge,  to  ulceration.  In  patients  whose  general 
health  is  impaired,  and  who  contract  vaginitis  through  the  irritation 
of  purulent  discharges  from  the  uterus,  membranes  of  a  diphtheritic 
character  may  form  on  the  mucous  surface.     These  same  membranes 


AFFECTIONS  OF  THE    VAGINA.  M15 


are  sometimes  found  in  connection  with  the  exanthemata.  Adhesions 
and  contractions  may  result,  which  almost  completely  occlude  the 
canal — adhesive  vatjiniiis. 

Symptoms. — Acute  vaginitis  reaches  a  climax  in  from  eight  to  ten 
days.  It  commences  with  a  sense  of  heat  and  burning  in  the  vagina, 
and  a  frequent  desire  to  pass  water.  There  is  a  muco-puruleut 
discharge,  which  occasionally  is  foetid.  Pelvic  and  vaginal  pain  or 
perineal  throbbing  follows.  Scalding  and  smarting  sensation  during 
micturition,  with  excoriation  of  the  vulva,  are  frequent  attendants. 
The  acrid  mucus  secreted  in  chronic  vaginitis  is  destructive  to  sper- 
matozoa, preventing  conception. 

Follicular  Vaginitis. 

Occasionally  small  follicular  cysts  are  found  in  the  neighbourhood 
of  the  cervix  uteri  in  either  fornix.  They  are  treated  in  the  same 
manner  as  directed  for  the  cervical  follicles,  incised  and  curetted. 
The  small  cavity  is  touched  with  a  fine  probe  point  dipped  in  carbolic 
acid.* 

Granular  Vaginitis. 

Causation. — In  this  variety  a  '  granular '  condition  of  the  mucous 
membrane  follows  the  acute  inflammation.  The  papillte  are 
enlarged  ;  the  mucous  follicles  also  are  hypertrophied.  It  is  more 
often  associated  with  pregnancy.  We  frequently  see  a  granular 
state  of  the  mucous  membrane  where  the  inflammatory  condition 
has  arisen  from  gonorrhceal  discharges,  or  where  endometritis  and 
cystitis  have  complicated  the  vaginitis.  It  is  important  to  recollect 
that  in  virgins  in  whom  there  is  no  reason  to  suspect  unchastity 
such  a  granular  state  may  be  present  associated  with  discharge. 

Physical  Signs  and  Symptoms. — If  the  vagina  be  cleaned  out, 
and  the  walls  wiped  with  cotton-wool,  so  as  to  remove  all  discharge, 
the  rug£e  will  be  seen  enlarged,  and  the  recto-vaginal  and  vesical 
septa  swollen.  The  dark-red,  rough,  granular,  eroded,  and,  here 
and  there,  fissured  appearance  of  the  mucous  membrane,  is  quite 
characteristic  of  this  form  of  vaginitis.  On  wiping  the  surface  of 
the  membrane  with  a  sponge  or  cotton-wool,  in  the  earlier  stages  of 
the  disease,  we  find  that  it  bleeds  readily.  The  os  uteri  and  external 
surface  of  the  cervix  are  frequently  engorged  and  granular.  There 
is  considerable  irritation  ;  the  patient  awakes  at  night,  disturbed  by 
the  itching,  smarting,  and   heat.     Pruritus   of  the  vulva  is  often 

*  See  Cysts  of  the  Vagina. 


846  DISEASES   OF   WOMEN. 


present,  aggravating  the  other  symptoms,  and  rendered  more  difficult 
to  treat  in  consequence  of  the  acrid  discharge  coming  from  the 
vagina.  We  must  not  forget  the  possible  complication  of  a  com- 
mencing carcinoma  of  the  cervix.  (For  treatment  of  Pruritus,  see 
p.  815.) 

Gronorrhoeal  Vaginitis  (Specific). 

Few  morbid  conditions  of  the  genital  organs  in  a  woman  are 
attended  with  such  serious  and  permanent  consequences  as  gonorrhoea. 
Despite  every  care  in  treatment,  the  latent  virus  may  from  time  to 
time  give  rise  to  a  variety  of  pelvic  disorders.  When  we  least 
suspect  it  the  gonorrhoeal  taint  is  the  source  of  some  obstinate 
affection  of  the  ovary.  Fallopian  tube,  uterus,  or  pelvic  peritoneum. 
It  is  not  so  much  on  account  of  the  immediate  symptoms  or  distress 
that  we  have  to  regard  gonorrhoea  in  the  female  as  a  serious  affec- 
tion, as  from  the  remote  results  which  for  years  after  the  disease  is 
contracted  may  continue  at  irregular  intervals  to  cause  xiterine  and 
other  pelvic  trouble.* 

Pyo-salpinx  following  Acute  Gonorrhoea. 

Edebohls  f  records  the  history  of  a  patient  who  had  specific  urethritis  four 
days  after  intercourse.  Vaginitis,  endometritis,  and  double  salpingitis  rapidly 
followed,  the  latter  being  diagnosed  on  the  tenth  day  after  infection.  At  the 
end  of  four  weeks  acute  pelvic  peritonitis  supervened,  and  the  enlarged  tube  was 
punctured  and  pus  escaped.  Five  weeks  after  infection  the  appendages  were 
removed.  Section  displayed  a  pelvic  peritonitis,  with  abundant  exudation, 
from  which  the  left  tube,  containing  about  two  drachms  of  pus,  was  readily 
detached,  on  account  of  its  recent  adhesions.  The  abdominal  end  of  the  tube 
was  found,  to  be  widely  distended,  but  glued  to  the  wall  of  the  pelvis.  The 
appendages  of  the  right  side  were  also  removed.  There  was  no  occasion  for 
drainage,  the  abdomen  was  closed,  and  the  patient  promptly  recovered. 

CulHngworth  J  has  forcibly  insisted  on  the  effects  of  gonorrhoeal  salpingitis 
in  sealing  up  the  pavilion  of  the  tube  by  adhesive  inflammation.  Should 
this  be  bilateral,  the  consequence  is  sterility,  and  he  argues  that  this  is  one 
explanation  why  prostitutes  are  so  often  sterile.  He  is  on  the  side  of  those 
who  regard  pyo-salpinx  as  a  frequent  sequence  of  gonorrhcsa,  and  considers  that 
the  views  of  Noeggerath  as  to  the  latency  and  incurability  of  gonorrhoea,  and 
the  possibility  of  such  latent  infection  being  roused  into  activity,  have  not 
received  the  attention  they  deserve.  As  we  have  already  pointed  out  in 
dealing  with  salpingitis,  Cullingworth  notices  the  freedom  of  the  vagina  from 
gonorrhoeal  vaginitis  in  a  large  proportion  of  cases,  while  the  ducts  of  the 

*  See  Gonorrhoeal  Proctitis. 

t  New  York  Jour,  of  Gyn.  and  Obstef^Dec,  1891. 

X   Brit.  Med.  Jour.,  July  20,  1889. 


AFFECTIONS   OF  THE    VAGINA.  847 

vulvo-vaginal  glands,  and  the  mucous  surfaces  of  the  vulva,  are  frequently 
attacked.  It  is  the  mncous  membrane  of  the  cervix  uteri  tliat  is  tlie  more 
special  site  of  the  infiaminatioii.  This  fact  accounts  for  the  more  serious  and 
permanent  adnexal  complications  of  gonorrhocal  inflammation.  We  have 
already  seen  how  syphilis  may  be  associated  with  gonorrhoea,  and  that  possibly 
the  syphilitic  poison  may  be  masked  by  it. 

With  all  these  observations  I  entirely  concur.  I  quote  them  here  to 
support  the  view  I  have  taken  in  past  editions  of  this  work  of  the  etiological 
importance  of  gonorrha?a,  both  acute  and  latent,  as  one  of  the  many  potent 
sources  of  pelvic  disorders  in  the  female. 

Gonorrhoeal  Infection  in  Childbed. — Leopold  *  insists  on  the  possibility  of 
the  fever  of  childbed  being  originated  by  the  gonorrhosal  virus,  which  latter 
has  been  present  previous  to  the  confinement  in  the  vaginal  discharges. 
Thus  the  condition  may  arise  quite  independent  of  any  vaginal  examination. 

Diagnosis. — This  must  depend  on  the  history  of  the  case,  the 
examination  of  the  husband,  the  intensity  of  the  symptoms,  and  the 
transmission  to  the  male  from  intercourse.  It  is  necessary  to  lay 
special  stress  on  the  extreme  care  with  which,  should  we  suspect 
gonorrhoea  in  a  married  woman,  we  must  investigate  the  case.  The 
gonococcus  of  Neisser  (Merismopedia  gonorrhoea)  should  be  sought  for 
in  the  discharge.f 

There  are  two  facts  which  have  a  very  important  bearing  on  the 
difTerentiation  of  this  aifection. 

1.  Other  causes  in  the  woman  than  that  of  gonorrhoea  may 
originate  blenorrhceal  discharge  in  the  male.  This  is  more  likely  to 
occur  in  men  of  a  gouty  temperament,  and  who  may  have  had  some 
latent  urethritis  existing,  of  a  non-specific  nature.  This  I  have 
frequently  noticed. 

'  I  have  seen,'  says  Sims,  '  many  cases  of  urethral  inflammation  in 
the  husband  that  were  unquestionably  contracted  from  the  wife, 
who,  however,  had  merely  a  leucorrhoea  of  an  acrid  character.' 

Guerin  explains  the  fact,  well  known  in  practice,  that  women  who 
are  apparently  healthy,  and  who  may  fancy  themselves  to  be  so, 
often  convey  infection  by  the  localization  of  the  disease  in  the  upper 
part  of  the  vagina  and  the  vaginal  cul-de-sac. 

2.  We  may  have  little  to  guide  us  save  the  intensity  of  the 
symptoms  and  the  urethral  complication,  and  no  collateral  and 
confirmatory  proof,  sufficient  to  warrant  us  in  coming  to  a  conclusion  ; 
we  must,  therefore,  be  extremely  cautious  in  expressing  an  opinion 
as  to  the  nature  of  the  disease. 

*  Cerdralh.f.  Gyn.,  1893. 

t  It  will  be  remembered  that  the  vaginal  epithelium  is  hostile  to  the  invabiou 
of  the  gonococcus.     (Author.) 


848  DISEASES   OF   WOMEN. 

The  attendant  should  judiciously  frame  an  excuse  for  seeing  either 
the  husband  or  the  wife.  Much  will  depend  on  his  tact  and  discre- 
tion in  extracting  from  either  the  facts  necessary  to  help  him  to 
a  conclusion,  without  arousing  suspicions  and  bringing  about  doubts 
of  chastity  and  marital  unhapjDiness. 

Symptoms  and  Physical  Sig-ns. — Every  symptom  of  simple 
vaginitis  is  exaggerated.  The  onset  of  the  attack  is  more  severe. 
The  discharge  is  more  profuse  and  purulent.  The  local  signs  of 
inflammation  are  intensified,  there  is  greater  scalding  on  passing 
urine,  and  more  swelling  of  the  vulva,  which  may  be  excoriated, 
and  the  discharge  from  it  tinged  with  blood. 

The  morbid  conditions  to  which  gonorrhoea  may  give  rise  are — 

Vulvitis  and  vulvar  abscess. 

Suburethral  abscess. 

Cystitis  and  ureteritis. 

Nephritic  inflammations . 

Metritis. 

Endometritis  (cervical  and  corporeal). 

Salpingitis  and  p)yo-salpinx. 

Ovaritis. 

Peri-uterine  phlegmon. 

Perimetritis. 

Sterility. 

Bubo. 

Treatment. 

Simple  Vaginitis — Acute  Stages. — Rest  in  bed ;  warm  baths ; 
vaginal  injections  containing  borate  of  soda,  Condy's  fluid  (51. — Oi.), 
laudanum,  decoction  of  poppy-heads,  belladonna  (such  warm  injec- 
tions are  to  be  used  gently  and  slowly).  The  bath  speculum 
(Fig.  49)  may  be  used  in  a  warm,  sitz-bath,  to  which  some  car- 
bonate of  soda  and  starch  have  been  added,  and  this  can  be  re- 
peated three  times  in  the  day.  The  warm  vaginal  douche,  to  which 
a  little  laudanum  is  added,  will  be  found  to  afibrd  great  relief. 
These  douches  can  be  used  three  times  daily.  The  nurse  or  the 
patient  herself  can  be  taught  how  to  secure  some  wool  with  a 
speculum  forceps,  and,  having  smeared  it  well  with  some  sedative 
ointment,  to  apply  it  to  the  vaginal  mucous  membrane  after  the 
douche.  At  night  a  medicated  glycerine  tainpon  of  belladonna  or 
hyoscyamus  and  cocaine  may  be  used.  This  can  be  applied  the  last 
thing  befoi^e  going  to  sleep,  and  removed  in  the  early  morning.     Later 


AFFECTIONS  OF   THE    VAGTNA.  849 


OQ  in  the  aifection,  tannin  (5ii.  ad  ^^i.)  may  be  added  to  the  glycerine, 
and  the  tampon  need  not  be  disturbed  for  twenty-four  hours.  Sleep 
may  have  to  be  secured  by  such  hypnotics  as  trional,  sulphonal, 
paraldehyde,  or  nepenthe.  The  bowel  must  be  kept  free  with  a 
saline  purgative.  The  diet  should  be  non-stimulating,  and  alcohol 
altogether  abstained  from.  If  there  be  urethritis  aad  vesical  irrita- 
tion, the  oils  of  cubebs,  copaiba,  or  santal,  prescribed  in  emulsion,  are 
of  service.     They  can  be  given  in  palatinoids  or  capsules. 

Decoction  of  pareira,  and  the  infusions  of  juniper,  uva  ursi,  and 
buchu  may  be  taken.  Diluent  drinks  and  infusion  of  linseed  should 
be  given. 

Second  Stage. — The  acute  stage  over,  mild  astringent  lotions  of 
sulpho-carbolate  of  zinc,  sulphate  of  zinc,  subacetate  of  lead,  alum, 
matico,  "borolyptol"  or  "  formolyptol,"  boric,  salicylic  or  tannic 
acid  can  be  used.  Perhaps  the  best  wash  will  be  found  to  be  that 
of  perchloride  of  mercury  CI  in  5000 ).  This  is  used  three  times  in 
the  day.  The  warm  douche  should  be  continued,  and  the  same 
sedatives  used  to  allay  irritation.  Vaginal  suppositories  of  cocaine, 
belladonna,  tannic  acid,  acetate  of  lead,  or  iodoform,  may  be  used  at 
night.  Any  uterine  complication  should  be  attended  to.  If  there 
be  a  fistulous  opening  into  the  vagina  this  should  be  closed.  Should 
the  disease  prove  obstinate,  the  vagina  may  be  mopped  out  with  a 
nitrate  of  silver  solution  or  carbolic  acid  and  glycerine. 

Treatment  of  Granular  Vaginitis. — Edis  spoke  highly  of  carbolic 
acid  (311. — 5iv.  ad  ^i.  glycerine)  in  cases  of  granular  vaginitis.  I 
have  found  excellent  results  from  the  use  of  chloride  of  zinc  (grs. 
XXX.  ad  5i'  glycerine j.  The  vagina  is  fi.rst  wiped  dry,  and  all  dis- 
charge is  removed.  It  is  then  packed  with  a  tampon  of  dry  absorbent 
cotton-wool.  This  is  left  in  for  a  few  minutes,  and  then  withdrawn. 
The  vaginal  walls  are  thus  completely  dried.  A  Fergusson's  specu- 
lum is  now  introduced,  and  during  its  withdrawal  the  entire 
vaginal  surface  is  swabbed  with  any  solution  we  wish  to  use.  Thus 
the  greatest  i-elief  from  the  seuse  of  pain,  heat,  and  itching  will  be 
obtained  by  swabbing  the  vaginal  walls  once  with  weak  solutions 
either  of  nitrate  of  silver  or  perchloride  of  mercury,  ten  grains  to  the 
ounce  of  the  former  and  ^  of  a  grain  to  the  ounce  of  the  latter.  It 
is  not  necessary,  save  in  rare  and  obstinate  cases,  to  use  very  power- 
ful solutions.  On  the  whole,  save  in  very  exceptional  cases,  I  think 
it  well  to  abstain  from  strong  and  heroic  remedies  in  vaginitis.  The 
solid  glass  vaginal  rest  will  be  found  a  useful  aid  in  dealing  with 
this  affection. 

3  I 


850 


DISEASES   OF    WOMEN. 


Treatment  of  Gonorrhoeal  Vaginitis. — There  are  some  precautions 
which  should  specially  be  observed  in  this  form  of  vaginitis  : — 

1.  In  the  acute  stage  any  forcible  injections  should  be  avoided  and 
simple  soothing  baths  used. 

3.  Before  the  employment  of  an  astringent  lotion,  the  acute  stage 
should  have  completely  subsided. 

3.  The  rectum  should  be  attended  to. 


Fig.  543. — Uteuus  Duplex— Left-sided  H^matometea  with  Ovary. 
(Emeet  Maevel.) 

The  riglit  ovary  was  the  size  of  a  hen's  egg,  the  left  that  of  a  goose's  egg — 
both  were  cystic.     The  organs  were  removed  by  supravaginal  hysterectomy.* 

4.  The  patient  should  be  kept  under  observation  for  some  time 
after  the  disease  is  apparently  cured. 

5.  The  chronic  and  relapsing  nature  of  the  affection,  the  liability 
of  the  patient  to  attacks  of  endometritis  and  ovaritis,  as  well  as  the 
latent  character  of  the  gonorrhoeal  virus,  should  not  be  lost  sight  of. 

Great  care  has  to  be  observed  with  regard  to  the  rectum  should 
*  Ann.  Gyn.  and  Fed.,  Nov.,  1903. 


AFFECTIONS   OF    THE    V Mi  IN  A. 


851 


there  be  any  rloubt  as  to  the  gonori'hrcal  nature  of  the  attack. 
The  bowel  may  bo  infected  by  contact  with  the  (lischar<;e.s,  or  in 
inserting  suppositories  or  administering  injections.  Should  this 
unfortunately  occur,  alkaline  and  antiseptic  washes  must  be  used. 

Atresia  of  Uterus  and  Vagina. 

Partial  or  complete  closure  of  the  vaginal  canal  or  of  the  vulvar 
orifice  may  exist,  either  as  a  congenital  malformation  or  an  acquired 
condition.     At  the  same  time  there  often  is  atresia  of  the  uterus. 

Complete  atresia  of  the  uterus  may  be  the  result  of  closure  of  either  the 
external  os  or  internal  isthmus.  If  there  be  closure  of  the  lips  of  the  uterine 
orifice,  the  entire  uterus  is  generally  distended,  the  walls  being  either 
hypertrophied,  or,  on  the  other  hand,  considerably  thinned  (Scanzoni).  If  the 
internal  isthmus  be  closed, 
the  cavity  of  the  body  is 
dilated. 

Congenital  Malforma- 
tions. 

It  is  convenient  here 
to  include  a  brief  refer- 
ence to  malformations 
of  the  genitalia.  Ano- 
malies of  the  ovaries 
have  been  already  re- 
ferred to.  From  the 
Wollfian  body  arises  the 
ovary. 

With  regard  to  mal- 
formations of  the  geni- 
tal organs,  the  student 
is  familiar  with  the  de- 
velopment of  the  canal 
of  Miiller  and  the  Wolf- 
fian body.  He  will  re- 
member that  from  the 
canals  of  Miiller  ai'ise 
the  Fallopian  tubes,  the  uterus  and  vagina,  which  are  in  the 
embryonic  stage  double.  A  malformation  of  the  uterus  or  vagina 
may  be  due  to  a  defect  in  any  degree  in  the  development  of  the  canala 
of  Miiller,  whether  that  defect  be  due  to  simple  arrest,  a  fault  of 


Fig.  544. — Didelphian  Uterus,  Vagina  divided 
BY  A  Partial  Septum.     (Oliver.) 

a,  right  segment;  t,  left  segment;  c,  cl,  ovary 
and  right  round  ligament ;  e,  ovary  and  left 
round  ligament ;  /,  Fallopian  tube ;  g,  left  cer- 
vix ;  h,  right  cervix ;  A",  septum  of  double 
vagina  (?,  j). 


852 


DISEASES   OF    WOMEN. 


fusion,  or  the  suppression  of  either.  We  might  thus  classify  the 
results  of  these  embryonic  accidents  of  development  in  the  adult 
as  follows  : — 

Malformations  of  the  Uterus. 

(a)  Complete  absence  of  uterus  ;  (h)  rvidimentary  uterus  ;  (c)  bi- 
partite uterus,  in  which  latter  the  neck  may  exist  and  the  defect  be 
in  the  body,  or  there  may  be  an  arrested  development  of  the  latter  ; 
(d)  infantile  uterus  ;  (e)  undeveloped  body,  with  preternaturally 
long  and  tapering  neck  ;  (/)  fcetal  uterus,  in  which  there  is  an 
advance  and  development  on  the  last  named. 

Malformations  of  the  Vagina. 

Absence  of,  complete  or  partial ;  according  to  Pozzi,  a  rudimentary 
vagina  is  due  to  persistence  of  the  vesbibular  canal,  and  arrest  of 


Fig.  545. — Uteeus  Didelphys.    (A.  Giles.) 

The  vaginal  portion  drawn  from  nature ;  the  supra-vaginal  portion 
semi-diagrammatic. 

development  of  portion  of  the  vagiiia.     Schrceder  believes  that  when 


AFFECTIONS   OF  THE    I'.l'.y.Vvl. 


868 


the  middle  of  the  vaginal  canal  persists,  but  is  closed  above  and 
below,  it  is  consequent  upon  an  obliteration  of  one  of  the  Miillerian 
conduits  at  the  upper  and  lower  end  of  the  canal.  Thus,  whether 
the  malformation  assume  the  form  of  closui'e  of  the  vagina,  a  par- 
titioning of  this  canal  by  a  partial  or  complete  septum,  a  double 
uterine  oritice  and  neck,  or  any  other  variety  of  uterine  abnormality 
depends  upon  correlative  deviations  from  the  noi'mal  development  of 
the  Miillerian  canals.  The  didelphian  (Ats ;  ScAtjSu?)  malformation  is 
that  in  which  no  fusion  occurs,  and  in  which  each  separate  neck 
opens  into  its  own  vagina.  If  the  vagina  be  absent  the  uterus  is 
often  abnormally  small,  rudimentary,  or  entirely  absent. 


Malformations  of  the  Hymen. 

In  referring  to  the  hymen,  I  have  already  fully  alluded  to  various 
abnormalities  in  its  shape  and  structure."' 

Pozzi  draws  attention  to  the  error  that  may  be  made  in  mistaking  an  over- 
development of  the  hymen  for  nymphfe,  and  thus  concluding  that  the  hymen 
is  absent,  but  the  most  common  form 
is  the  labiate  (Brouardel).  A  slit  sepa- 
rates two  valves,  passing  backwards 
from  the  vaginal  bulb  in  front.  In  the 
newly  born,  a  bougie,  with  a  diameter 
of  0'0009  m.,  can  be  passed.  This 
form  may  persist  during  life.  In  a 
child  of  seven  years  a  bougie  0"01  m. 
in  diameter  can  be  introduced,  and  in 
a  marriageable  girl  the  finger  pene- 
trates easilj'.  Brouardel  makes  these 
observations  (most  important  from  the 
point  of  view  of  legal  medicine)  on  the 
hymen  of  young  girls.  During  exami- 
nation with  the  thighs  separated,  the 
membrane  is  so  tense  that  the  finger 
cannot  penetrate,  but  if  they  be  ap- 
proximated the  hymen  folds  itself  like 
a  pouch  and  the  posterior  valve  is  depressed,  the  hymeneal  orifice  thus 
becoming  larger  and  more  distensile.  Penetration  oifers  no  difficulty,  and 
it  is  well  to  note  that  this  applies  as  much  to  the  penis  of  an  accused  person 
as  to  the  finger  of  an  expert. 

Varieties. — Pozzi  describes  the  following  forms  :  (a)  annular  ;  (b)  circular 
{orificeniraV) ;  (c)  semi-lunar  {orifice  nearer  uj)per  herder) ;  (d)  falciform ; 
(e)  fleshy  {of  various  shapes);  {{) fringed;  {g)  fundibuliform ;  (h)  hyper- 
trophic;   (i)   divided  {and    no    openings    separated    hy   a  partition);    (j) 


Fig.    546.  —  H^mato-colpos,    from 
Atresia  of  the  Vagina.    (Pozzi.) 


*  See  pp.  11,  12. 


8n4  DISEASES   OF    WOMEN. 

cribriform;  (k)  columnated  (continuation  of  the  pillar  of  the  vagina  on  the 
posterior  surface  of  the  hymen).  Pozzi  states  that  in  cases  of  atresia  of  the 
hymen,  when  it  is  said  to  be  imperforate,  it  is  simply  joined  to  an  adhesion 
of  the  vaginal  walls  (heematocolpos)  which  has  imprisoned  menstrnal  fluid, 
and  from  which  it  is  detached  when  this  is  evacuated  (Matthews  Duncan, 
Schroeder,  Godfrey).     To  these  I  have  added  "  Folding  "  hymen. 

Where  the  introitus  is  contracted,  and  the  hymen  is  a  cause  of 
obstruction,  being  persistent  or  having  sensitive  margins,  the 
carunculse  being  also  hypertrophied  or  irritable,  resection  of  the 
hymen  should  be  performed.  By  circumferential  incision,  or  an 
elliptical  one  at  either  side,  the  hymen  is  removed  and  the  edges 
of  the  folds  brought  neatly  together  with  a  continuous  gut  suture. 
When  the  wound  has  healed,  the  glass  dilator  may  then  be  used  in 
the  instance  of  a  woman  to  whom  coitus  has  been  painful. 

Among  the  anomalies  of  structure  noted  are  (1)  excessive  thick- 
ness ;  (2)  great  rigidity  ;  (3)  vascularity.  Congenital  absence  of 
the  hymen  is  a  condition  the  occurrence  of  which  is  to  be  regarded 
with  grave  doubt. 

Atresia  of  the  Uterus. — The  congenital  forms  have  been 
enumerated. 

Acquired  Atresia  of  the  Uterus. — The  more  common  causes 
producing  acquired  atresia  of  the  uterus  are — 

Parturition. 
The  use  of  caustics. 
Operations  on  the  cervix. 
Cervical  endometritis. 
Senile  atrophy. 

Physical  Signs  of  Atresia  of  the  Uterus — 

Absence  of  menstruation. 

Presence  of  a  tumour  in  the  hypogastrium. 

A  uterine  tumour  felt  through  vagina,  which  gives  a  sensation 

of  elasticity. 
Impossibility  of  passing  the  uterine  sound. 

Symptoms. — The  symptoms  will  be  those  which  we  have  already 
considered  as  resulting  from  absence  of  menstruation.  The  patient 
also  suffers  from  the  consequences  of  the  occlusion  of  the  genital 
canal  and  the  local  accumulation  of  blood.     These  are — 

Accumulation  of  blood  in  the  uterus — hsematometra. 
Accumulation  of  blood  in  the  Fallopian  tube — pseudo  hsemato- 
salpinx  (vide  Hsemato-salpinx). 


AFFECTIONS  OF  THE    VAGINA. 


855 


Accumulation  of  serum  in  the  uterus — hydrometra. 

Perimetritis. 

Pelvic  hiomorrhage. 

Vicarious  hajmorrhage. 

Rupture  of  the  uterus  or  Fallopian  tube — septicemia  and  sepsis. 

Atresia  of  the  Vagina. — This  condition  is  either  congenital  or 
acquired. 

Congenital  Atresia. — In  congenital  atresia,  which  is  very  rare, 
there  is  arrest  of  development  leading  to  complete  or  partial 
absence  of  the  vagina. 
The  hymen  may  be  im- 
perforate. In  many 
cases,  though  a  super- 
ficial examination  gives 
the  idea  of  complete 
closure  of  the  vaginal 
oritice,  if  care  be  taken 
a  small  aperture  will 
be  detected  under  the 
urethra,  and  through 
this  the  menstrual  flow 
has  escaped.  In  such 
a  case  of  incomplete 
atresia,  menstruation  is 
frequently  erratic  in 
quantity  and  time  of  re- 
currence. A  thorough 
examination  of  the  con- 
dition can  only  be  made 
by  means  of  a  finger  in  the  rectum,  and  the  sound  passed  into  the 
bladder.  The  urethra  may  take  the  place  of  the  vaginal  canal, 
the  OS  uteri  opening  into  it. 

Congenital  Absence  of  the  Vagina. — rormation  of  Vaginal  Cavity.* — Gulmi  t 
reports  a  case  in  which  the  internal  genitalia  were  absent,  a  translucent 
membrane  closing  the  vaginal  introitus,  in  a  woman  aged  29,  who  bad  been 
manied  for  nine  years  without  having  bad  complete  coitus.  Tbe  urethra 
was  normal.  He  performed  a  plastic  operation  by  exposing  and  separating 
the  tissues  between  the  urethra  and  rectum  to  tbe  depth  of  11  cms.  Having 
temporarily  filled  this  cavity  with  iodoform  gauze,  two  days  later  be  grafted 
skin  from  a  live  ben  on  to  the  roof  of  tbe  artificial  canal  which  be  had  made. 


Fig.  oil. — Absent  Vagina  with  Atresia  of 
THE  Uterus.     (Legend.) 


See  pp.  176,  807. 


t  La  Clinica  Ostetrica,  Dec,  1902. 


856  DISEASES   OF   WOMEN. 

After  eight  days  the  grafting  proved  successful.  A  median  incision  was  now 
made  along  the  internal  surface  of  the  entire  length  of  the  labia  minora,  and 
above  this  incision  the  upper  halves  were  split  vertically  into  two  parts  of  equal 
thickness.  The  inner  layers  of  each  side  were  grafted  on  to  the  internal 
walls  of  the  freshened  vagina.  When  the  parts  had  healed,  there  was  a 
vaginal  cavity  about  6  cms.  in  depth. 

Von  Ott,  in  a  case  in  which  he  removed  a  myomatous  uterus  from  a  patient 
who  suffered  from  emansio  meusium,  made  an  artificial  vagina  as  follows: — 
The  wall  of  the  bladder  was  in  immediate  contact  with  the  rectum,  and 
representing  the  vagina  was  a  shallow  groove,  through  the  middle  of  which  ran 
an  obliquely  directed  fold  of  skin,  some  2  cms.  high.  This  fold  of  skin  was 
split  into  two  flaps.  Believing  that  he  had  a  hsematometra  to  deal  with,  Ott 
forced  his  finger  through  this  wound  and  discovered  the  myomatous  uterus. 
The  flaps  of  skin  at  either  side  were  turned  back  into  the  canal  which  he  had 
made,  and  were  sutured  to  the  peritoneum,  the  opening  being  then  closed.  In 
a  year  and  a  half  the  artificial  vagina  could  hardly  be  distinguished  from  a 
natural  one. 

Coitus  througli  tlie  Urethra. — In  a  case  recorded  by  Breitenfeld  *  a  patient, 
aged  21,  who  had  never  menstruated,  had  genital  hgemorrhage  after  her  first 
coitus,  the  urine  remaining  bloody  for  a  considerable  time.  The  breasts  and 
external  genitalia  were  quite  normal.  Below  the  hypertrophied  clitoris  there 
was  a  slit  which  admitted  the  index  finger,  which  passed,  without  pain,  into 
the  bladder.  There  was  no  incontinence  of  urine.  The  introitus  was  closed, 
there  being  only  a  blind  depression  with  a  cicatricial  base,  and  two  blind 
openings  at  either  side  a  few  centimetres  deep.  The  sole  evidence  of  internal 
genitals  was  a  cord  representing  the  right  ovarian  ligament,  and  a  rudimentary 
right  ovary.  The  only  trouble  from  coitus  through  the  urethra  was  occasional 
heematuria. 

Acquired  Atresia. — The  principal  causes  of  acquired  vaginal 
atresia  are — 

Vaginitis, 
Parturition. 
Injuries,  burns,  etc. 
Syphilitic  ulceration. 
Caustics.  ^ 
Physical  Signs — 

Absence  of  the  vaginal  canal. 

Absence  of  menstruation  after  puberty. 

Cicatricial  adhesions  in  the  vagina. 

Imperforate  or  persistent  hymen. 

Bulging  of  the  hymen. 

Fluctuating  tumour  detected  per  rectum. 

Presence  of  uterus  ascertained  by  the  recto- vesical  examination. 

Enlargement  of  the  abdomen. 

*  CentraTb.  f.  Gyn.,  1902,  No.  15. 


AFFECTIONS   OF  THE    VAGINA.  857 


In  the  case  of  double  vagina,  there  may  be  atresia  of  one  vaginal 
canal,  the  other  Vjeing  permeaV^le  ;  a  longitudinal  vaginal  tumour, 
cylindrical  in  shape,  '  tense  and  fluctuating,'  is  felt  through  the 
permeable  vagina. 

Cullingworth  has  recorded  an  interesting  case  of  retained  menses,  in  which 
the  vagina  was  occluded  throughout  its  lower  portion  by  a  membranous 
structure  which  was  not  hymen.  The  vaginal  wall  was  hypertrophied.  He 
is  of  opinion  that  tlie  obstruction  in  these  cases  is  not  at  the  hymen,  but 
behind  it ;  the  hymen  frequently  lying  on  the  obstructing  membrane,  and  so 
closely  adherent  to  it  as  only  to  be  with  difficulty  recognized  as  a  separate 
stmcture. 

I  operated  on  a  case  somewhat  similar  to  this  one  of  CidHng worth's.  Tiie 
girl  was  sixteen  years  of  age  ;  the  hymen  was  normal,  but  the  hymeneal 
orifice  was  very  small.  The  girl  was  developing  symptoms  of  septicaemia,  wth 
local  signs  of  uterine  and  abdominal  tenderness.  I  made  an  incision  through 
a  rather  dense  partition,  and  then  forced  a  passage  with  my  finger,  thus 
liberating  a  quantity  of  black,  tarry  fluid.  The  cavity  was  well  washed  out 
with  perchloride  of  mercury,  and  tamponed  with  iodoform  gauze.  The  patient 
recovered  perfectly  after  a  short  illness. 

Symptoms  (after  puberty)— 

Periodical  pain  and  tenderness  in  the  hypogastric  region. 

Uterine  colic. 

Vesical  irritation. 

Retention  of  urine. 

Abdominal  tenderness. 

Constitutional  symptoms  of  amenorrhcea. 

Vicarious  haemorrhage. 

Symptoms   of    Inflammation   and   Internal   Hsemorrhage   from 
Retained  Menses- 
Cold  Skin. 
Rapid  pulse. 
Rigors. 
Vomiting. 

Violent  abdominal  and  uterine  pain. 
Elevation  of  temperature. 

The  principal  dangers  to  apprehend  are — 

Perimetritis. 

Peritonitis. 

Pelvic  haemorrhage. 

Septica:;mia. 


858  DISEASES   OF    WOMEN. 

The  retained  blood  is  dark  coloured,  of  the  consistence  of  treacle ; 
there  are  no  coagula. 

Treatment— By  Aspiration  or  Crucial  Incision.— Operative  inter- 
ference may  be  demanded  :  1.  To  set  free  imiDrisoned  menstrual 
fluid  ;  2.  To  permit  sexual  intercourse.  In  all  operations  for  uterine 
or  vaginal  atresia  the  two  principal  dangers  which  have  to  be  feared 
are — 

(a)  The  admission  of  air,  and  septic  changes  in  the  imprisoned 
fluid. 

(h)  Uterine  contractions,  which  may  cause  a  retro-flow  through 
the  Fallopian  tubes. 

To  avoid  the  first  danger,  every  aseptic  precaution,  before, 
during,  and  after  the  operation,  should  be  taken  to  prevent  sepsis. 

Aspiration. — To  prevent  the  second  complication,  it  is  better  to 
aspirate  gradually,  Bartlett's  aspirator  being  used  (Fig.  72).  If 
the  uterus  be  distended  with  fluid,  and  the  atresia  situated  in  the 
cervical  canal,  not  more  than  one-third  of  the  fluid  should  be  drawn 
ofi"  on  the  first  occasion.  A  week  may  be  allowed  to  elapse  before 
a  repetition  of  aspiration;  and  this  careful  emptying  of  the  uterus 
is  continued  until  the  entire  fluid  is  removed.  The  vagina  must 
be  well  tamponed  after  each  operation. 

The  branched  dilator  and  cannula  of  Landau  (Fig.  121)  may  be 
used  with  safety. 

Opening  the  Uterine  Canal. — The  operation  for  opening  the  canal 
of  the  uterus  has  to  be  performed  with  the  greatest  care.  The 
vagina  is  thoroughly  sterilized  in  the  manner  directed  (pp.  129,  130.) 

Gaillard  Thomas's  Method. — '  The  cervix  is  steadied  with  a 
tenaculum,  a.nd  a  long  exploring  needle  is  passed  into  the  uterine 
cavity.  The  sense  of  resistance  once  over-,  the  escape  of  a  drop  of 
blood  will  assure  the  operator  of  his  success  in  reaching  it.  Then 
putting  into  the  gutter  of  the  needlg  a  delicate  tenotome,  he  pushes 
it  upwards  to  the  required  distance  to  open  the  canal.  This  section 
is  repeated  on  the  other  three  sides  ;  the  cavity  of  the  uterus  is 
syringed  out  with  carbolized  water,  very  gently  forced  from  a  small 
syringe ;  a  glass  plug  is  inserted  in  the  cervix,  and  the  vagina 
tamponed  as  after  aspiration.' 

Crucial  Incision. — If  crucial  incision  of  the  imperforate  hymen 
be  determined  upon,  a  self -retaining  drainage  tube  is  passed  into 
the  vagina  through  a  small  opening,  and  the  fluid  is  allowed  to 
drain  for  some  time— generally  for  an  hour  or  more — into  a  large 
sponge  wrung  out  of  some  weak  (^  per   cent.)  formalin  solution, 


AFFECTIONS  OF   THE    YAH  ISA.  859 

which  is  pressed  against  the  vulva  and  retained  there.  When  this 
is  removed,  a  crucial  incision  is  made  in  the  hymen,  and  any  fluid 
remaining  is  evacuated.  The  vagina  is  then  douched  out  with  a 
perchloride  (1  in  2000)  or  formalin  (1  in  1000)  solution,  and, 
when  it  is  well  cleansed,  is  packed  with  iodoform  gauze.  The 
following  (lay  the  gauze  is  removed,  and  the  vagina  is  again 
douched.  This  is  repeated  for  some  days,  until  all  risks  from  any 
septic  infection  have  passed. 

Rauscher*  has  shown  that  a  hsemorrhagic  sacto-salpinx  may  result 
from  acquired  vaginal  atresia  as  a  consequence  of  infective 
inflammatory  changes.  He  performed  salpingo-oophorectomy,  and 
having  opened  the  uterine  cavity  he  emptied  it  of  the  contained 
blood,  and  pushed  a  forceps  into  the  obstructed  vagina  through  the 
uterus. 

Case  of  Hsematometra,  Hsemato-salpinx,  and  Hsemato-colpos. 

Christopher  Martin,  in  a  case  of  haimatometra  and  hsemato-salpinx  due  to 
atresia  of  the  vagina,  found  that  the  bladder  and  rectum  were  in  contact,  the 
vagina  ending  one  inch  above  the  hymen,  its  anterior  and  posterior  walls 
being  fused  together  to  the  extent  of  three  inches.  He  opened  the  abdomen, 
and  found  the  uterus  distended  with  menstrual  blood,  and  as  large  as  at  the 
sixth  month  of  pregnancy.  At  either  side  the  Fallopian  tubes  were  filled 
with  blood,  the  left  one,  at  the  pavilion  end,  being  dilated  into  a  globular 
mass  four  inches  in  diameter  and  connected  to  the  uterus  by  a  very  long 
pedicle.  The  upper  fourth  of  the  vagina  was  also  distended  with  retained 
menstrual  blood.  The  uterus  was  incised  in  the  middle  Hne,  and  its 
sanguineous  contents  evacuated.  It  was  then  irrigated  and  sponged  out. 
Myo-hysterectomy  was  next  performed.  The  cervical  stump  was  fixed  by 
silkworm-gut  sutures  into  the  lower  angle  of  the  incision,  the  internal  os  being 
flush  with  the  skin,  and  the  peritoneal  cavity  being  carefully  isolated.  A 
glass  drainage-tube  was  passed  through  the  gaping  cervix  down  to  the  bottom 
of  the  sac,  and  the  abdominal  toilette  completed.  The  patient  made  an 
excellent  recovery.  The  cervical  canal  for  some  time  exuded  a  little  glairy 
mucus  at  the  lower  end  of  the  abdominal  wound. 

Amussat's  and  Dupuytren's  Operations. — In  the  operation  of  Amussat  the 
steps  are :  (1)  A  catheter  is  introduced  into  the  bladder,  and  held  by  an 
assistant,  and  the  finger  of  the  left  hand  is  carried  into  the  rectum  ;  (2)  a 
transverse  incision  is  made  through  the  integument,  between  the  rectum  and 
urethra ;  (3)  the  handle  of  the  knife  and  the  finger  are  used  to  tear  o[)en  a 
passage  to  the  tumour  ;  (4)  the  tumour  is  opened  with  a  trocar  and  cannula, 
a  director  is  introduced  through  the  cannula,  and  the  latter  is  withdrawn ; 
(5)  a  knife  is  used  on  the  director  to  enlarge  the  opening.  In  Dupuytren's 
operation,  an  incision  is  made  in  the  first  instance  transversely.     With  the 

*Monat8.f.  Gel.  u.  Gyn..  May,  1903. 


860  DISEASES   OF    WOMEN. 

finger  and  knife-handle,  the  tissues  are  then  torn  through  until  the  tumour 
is  reached.  A  trocar  is  plunged  into  it,  and  the  fluid  is  evacuated.  By 
means  of  a  perforated  sound  the  opening  is  enlarged,  and  the  cavity  is  then 
washed  out  with  a  catheter,  and  some  warm  antiseptic  water. 

Rupture  of  the  Vagina. — Rommel  '^  has  reportsd  a  case  of  rupture 
of  the  vagina.  The  accident  occurred  through  the  lifting  of  a  heavy 
kettle.  Death  followed  from  the  prolapse  of  a  large  portion  of  the 
small  intestine,  part  of  which  was  detached  from  the  mesentery. 
The  aperture  into  the  vagina  measured  4  cms.  in  diameter. 

Syphilis. — For  syphilitic  affections  of  the  vagina,  see  chapter  on 
the  Yulva. 

Prolapse  of  the  Vag'ina. 

In  discussing  prolapse  of  the  uterus  and  elongation  of  the  cervix 
it  was  necessary  to  refer  to  vaginal  prolapse. t  It  may  exist  apart 
from  any  descent  of  the  uterus.  When  the  vaginal  protrusion 
occurs  as  a  primary  affection,  it  is  more  likely  to  lead  through 
traction  to  supra-vaginal  elongation  of  the  cervix  than  to  pro- 
lapsus uteri.  On  the  other  hand,  the  three  conditions,  prolapse  of 
the  uterus,  elongation  of  the  cervix,  and  vaginal  inversion,  are 
frequently  associated. 

Cystic  Tumours  in  the  Vag'ina. — Kelly  divides  vaginal  cysts  accord- 
ing to  their  sources  — the  vaginal  glands,  the  scarred  tissue  following 
a  wound,  or  Gartner's  ducts.  He  supports  Eouget's  position  with 
regard  to  the  glandular  origin  of  the  cysts,  quoting  an  instance  of  a 
vaginal  cyst  which  was  lined  with  columnar  epithelium — a  flattened 
vaginal  gland,  lined  with  the  same  epithelium,  lying  between  the  cyst 
and  the  characteristic  epithelium  of  the  vagina.  In  cysts  arising 
from  the  epithelium  of  scar  tissue,  the  epithelium  is  squamous.  Those 
arising  from  Gartner's  ducts  are  very  rare,  occur  in  the  vaginal 
vault,  and  reach  to  the  folds  of  the  broad  ligament.  Atresia  of  a 
rudimentary  horn  of  the  uterus,  which  forms  a  fluctuating  tumour 
in  the  vaginal  vault,  a  sub-ureteral  abscess,  or  the  cystic  dilatation 
of  a  blind  ureter  beneath  the  urethra,^  are  instanced  by  Kelly  as 
likely  to  be  confounded  with  vaginal  cysts. 

Hydatid  Cysts. — Marion  §  has  included  another  source  of  origin 
of  vaginal  cysts — namely,  hydatid.     These,  he  says,  are  very  rare. 

*  Deutsclie.  zeits.f.  Chir.,  bd.  Ixiv.,  No.  7. 

t  In  the  chapter  on  Prolapse  of  the  Uterus,  the  reader  will  find  discussed  all 
the  various  correlative  conditions  and  sj'mptoms  that  are  associated  with  vaginal 
jDrolapse,  and  the  different  methods  of  treatment  by  operation  or  otherwise. 

X  Orthmann,  Central./.  Gyn.,  1893,  Xo.  7.  '         §  Gaz.  des  Hop.,  Feb.  1,  1902. 


AFFECTIONS  OF   THE    VAGINA.  801 

Primary  Echinococcus  of  the  Genitalia. 

De  ^'l■ies  *  has  reported  a  case  operated  upon  for  interstitial  myoma — it 
proved,  however,  to  be  a  true  hydatid  cyst.  Only  seven  genuine  cases  have 
been  recorded,  and  he  upholds  the  view  (contrary  to  Freund's  opinion)  that  the 
parasitic  invasion  may  be  primary  through  the  circulation  and  not  occun-ing 
through  the  rectum.     The  uterus,  tubes,  and  ovaries  have  all  been  invaded. 

The  contents  of  vaginal  cysts  are  at  times  thready  and  gelatinous, 
or  brownish  and  sanguineous.  In  those  I  have  met  with,  the  fluid 
has  been  clear.  Marion  describes  the  capsule  of  the  cyst  as  consisting 
of  a  layer  of  epithelium  lined  connective  tissue.  The  epithelium 
may  be  wanting,  and  varies  in  character,  being  squamous  or 
cylindrical.  Some  have  their  source  from  the  glands  occasionally 
found  in  the  vaginal  mucosa,  while  others  are  serous  cysts  (hygro- 
mata).  Those  which  are  derived  from  the  glands,  from  Gartner's 
or  Miiller's  ducts,  have  a  congenital  origin  (Wolff's  or  Miiller's 
ducts,  or  the  Wolifian  bodies). 

Diagnosis. — Care  must  be  taken  not  to  confound  a  vaginal  cyst 
in  the  anterior  wall  with  a  urethrocele  or  cystocele,  or  one  in  the 
posterior  wall  with  a  rectocele.  A  softened  vaginal  thrombus,  a 
lateral  haematocolpos,  a  cystic  ovary  in  the  pouch  of  Douglas,  a  cyst 
of  the  broad  ligament,  and  a  vaginal  hernia,  are  other  conditions 
liable  to  be  mistaken  for  a  cyst  of  the  vagina. 

Eoger  "Williams  shows  the  rarity  of  the  presence  of  any  large  cysts  in 
the  vagina  through  the  fact  that  in  five  thousand  women  submitted  to 
examination  at  the  Johns  Hopkins  Hospital,  only  two  instances  of  cysts  as 
large  as  an  egg  occurred. 

I  have  myself  removed  a  cyst  the  size  of  a  large  hazel  nut  fi'om  the  anterior 
wall  of  the  vagina. 

^Mlliams  classifies  vaginal  cysts  into  (a)  Wolffian ;  (b)  Miillerian ;  (c)  those 
derived  from  '  rests '  of  the  secretory  structure  of  the  Wolffian  body  in  the 
mucosa  of  the  cervix  uteri,  and  those  of  the  vulva  mucosa ;  {cT)  endothelial 
cysts  ;  and  (e)  parasitic  cysts.f  The  persistence  of  the  Wolffian  duct  in  the 
adult  explains  the  presence  of  some  vaginal  cysts.  Such  WblSian  cysts 
generally  contain  clear  pale  yellow  fluid.  At  times  the  contents  are  purulent. 
At  times  they  are  viscid  or  atheromatous,  resembling  those  found  in  the 
cervix  uteri  (Roger  Williams). 

'  Papuliferous '  cysts  have  been  met  with  in  the  para-uterine  and  para- 
vaginal connective  tissue,  more  particularly  in  the  neighbourhood  of  the 
portio  vaginalis.  Such  cysts  also  arise  along  the  course  of  the  Wolffian 
ducts.     In  the  case   of  the  Miillerian  cysts  arising  from   '  rests '  of  the 

*  Monats.f.  Geb.  u.  Gyn..  March,  1904. 

t  Eoger  Williams,  '  Vaginal  Tumours  with  Special  Eeference  to  Cancer  and 
Mvoma.'     1904. 


862  DISEASES   OF   WOMEN. 

Miillerian  ducts,  Freund  describes  such  as  present  in  the  portio  and  upper 
part  of  the  vagina.  '  They  are  deeply  seated  and  thick  walled,  comprising 
a  well-developed  musculosa.  A  single  layer  of  columnar  epithelium  lines 
their  interior,  which  is  often  ciliated,  and  may  present  involutions  and  crypts, 
while  their  contents  are  viscid  or  white-of-egg-like  fluids.  Other  cysts  are  ' 
caused  by  '  the  distension  of  blood,  pus,  or  mucous  of  the  blind  pouch  not 
uncommonly  formed  by  the  rudimentary  second  vagina  in  cases  of  imperfect 
duplicity  '  (Roger  Wilhams).  They  are  lined  by  a  dermo-papillary  membrane. 
Vaginal  cysts  have  been  described  as  originating  from  the  summit  of  the  vagina; 
they  are  small  cysts  lined  by  cyHndrical  epithelial  cells  identical  with  those 
lining  the  cervical  mucosa,  and,  like  these  latter,  secreting  a  thick  mucus. 
Such  cysts  Roger  Williams  classes  under  the  head  of  '  cysts  arising  from 
"  rests  "  of  the  cervical  mucosa.'  Another  class  of  cysts  are  those  found  in 
the  neighbourhood  of  the  vulva.  They  are  of  the  sebaceous  type,  their 
contents  being  of  an  atheromatous  or  cholesteatomatous  character,  and  they 
are  lined  by  modified  epidermoidal  cells.  Williams  classifies  dermoid  cysts 
of  the  vagina  under  three  heads : — Implantation  cysts,  true  dermoids,  and 
cysts  derived  from  '  rests  '  of  the  vaginal  epidermis.  The  traumatic  implan- 
tation cj'sts  have  their  germs  in  small  grafts  of  epidermis,  the  consequence 
of  some  operative  trauma.  The  epidermoid  cyst  is  a  result.  True  dermoid 
cysts  have  been  found  in  various  situations  in  the  connective  tissue,  both 
anteriorly  and  posteriorly  between  the  bladder  and  uterus  and  the  cervix 
uteri  and  rectum,  as  also  between  the  vagina  and  rectum,  and  encroaching 
on  all  these  organs.  They  are  generally  '  solitary,  unilocular,  thin-walled, 
and  of  comparatively  simple  structure.'  They  may  contain  epidermoidal 
structures,  and  are  lined  by  multilaminar  papillated  epidermis.  They  usually 
contain  atheromatous  material  or  grumous  fluid.  Williams  gives  interesting 
examples  of  such  cysts  from  cases  recorded  by  Mahomed,  Merriman,  Mannel, 
Beyea,  Geyl,  and  others.*  Endothelial  cysts,  and  those  of  an  angiomatous 
or  lymphangiomatous  nature,  are  very  rare.  True  myomata  are  hardly 
ever  seen.  Hydatid  cysts  are  occasionally  found  in  the  vagina,  to  be  dis- 
criminated (Williams')  •'  by  their  translucent,  laminated,  detachable,  retractile 
lining,  and  by  the  clear  watery  fluid  they  contain,  in  which  the  characteristic 
booklets  may  be  found.' 

Differentiation. 

In  differentiating  vaginal  cysts  from  other  conditions,  the  follow- 
ing points  are  of  importance  :  Thoy  are  generally  single,  painless, 
and  give  rise  to  little  inconvenience.  Pressure  does  not  affect  the 
cyst  as  it  would  a  hernial  protrusion.  A  careful  recto-vaginal 
bimanual  examination  will  locate  the  cyst  in  the  vaginal  wall, 
and  enable  us  to  distinguish  it  from  any  i3uid  accumulation  in 
the  pouch  of  Douglas.  A  urethrocele  or  cystocele  will  be  deter- 
mined by  a  vesical  examination  with  the  sound  in  the  bladder  and 

*  Lib.  cit,  p.  77. 


AFFECTIOXS    OF    THE    VAGINA.  SGH 

the  finger  in  the  vagina,  and  a  rectocele  by  a  rectal  exaraination,  as 
well  as  the  disappearance  of  the  swelling  when  the  bladder  or  rectum 
are  replaced  by  digital  pressure.  A  suppurating  cyst  causes  pain, 
but,  unless  it  be  high  in  the  vagina,  we  are  not  likely  to  mistake  it 
for  a  pelvic  phlegmon  or  abscess.  Puncture  with  a  fine  exploring 
needle  will  determine  the  nature  of  the  contents  of  the  cyst,  and 
help  us  to  define  its  character. 

Vaginal  Cysts  and  Pregnancy. 

A  cystic  tumour  of  the  vagina,  removed  by  Couvelaire  "'  (Paris) 
from  a  woman  thirty-three  days  after  labour,  contained  a  thick 
fibrinous  and  opalescent  fluid,  and  the  wall  consisted  of  '  (1)  a 
stratified  layer  of  pavement  epithelium,  (2)  a  basement  membrane 
of  variable  thickness,  (3)  a  musculo-vascular  layer.  He  does  not 
advise  interference  with  such  cysts  during  pregnancy  ;  should  they 
offer  any  obstruction  to  delivery  they  should  be  opened  freely  with 
the  knife  and  afterwards  dealt  with  according  to  circumstances.' 

Fibromyomata. 

Furneaux  Jordan  has  summarized  the  conclusions  of  Richard 
Smith,t  who  collected  and  reviewed  the  particulars  of  100  cases 
of  fibromyomatous  tumours  of  the  vagina  recorded  up  to  1902,  in- 
cluding 52  published  by  Kleinwachter  in  1882.  These  records 
prove  that  '  fibroma  (including  myoma  and  fibromyoma  of  the 
vagina)  is  a  rare  disease.  It  is  found  most  frequently  in  women 
between  30  and  40,  but  has  been  observed  at  ages  ranging  from 
20  to  70.  It  apparently  occurs  independently  of  civil  condition. 
No  proof  can  be  deduced  to  show  that  it  affects  fertility.  When 
large,  it  may  obstruct  labour.  It  may  or  may  not  affect  coitus. 
In  certain  cases  menstruation  may  be  increased.  The  tumours, 
when  small,  rarely  produce  symptoms  of  consequence ;  when  large, 
they  may  prove  to  be  the  source  of  considerable  suffering  and  even 
danger.  Symptoms,  when  present;  are  pain,  ha?morrhage,  discharge, 
obstruction  to  the  bladder,  and  more  rarely  to  the  bowel.  No  exact 
division  into  fibroma,  myoma,  and  fibromyoma  can  be  made.  The 
tumours  grow  from  the  anterior  and  posterior  walls  in  the  proportion 
of  about  two  to  one  ;  they  may  be  sessile  or  polypoid,  and  with  rare 
exceptions  they  are  single.  They  are  of  very  slow  growth,  and  prone 
to  oedema,  neci-osis,  and  ulceration.' 

*  Ann.  Gya.  Obst,  IMarch,  1900 ;  and  Brit.  Gyn.  Jour.,  1903. 
t  Brit.  Gyn.  Jour.,  1902 ;  and  Amer.  Jour.  Obdet.,  Feb.,  1902. 


864  .   DISEASES   OF    WOMEN. 

Later,  Potal  *  (Lille),  from  the  literature  of  160  published  cases, 
arrives  at  these  conclusions  : — 

They  may  grow  at  any  time  of  life,  but  84  per  cent,  occur  during  the  child- 
bearing  age.  The  majority  have  pedicles,  but  some  are  broadly  attached 
and  occasionally  without  any  capsule ;  the  heaviest  recorded  weight  was 
5' 2  5  kilogs.  The  tumours  were  multiple  in  8  out  of  120  cases,  and  uteriue 
fibromata  coexisted  in  3  or  4;  occasionally  vaginal  fibromata  are  tumours 
which  have  escaped  from  the  uterus,  as  may  be  known  by  the  pedicles  pass- 
ing from  them  to  the  portio.  The  seat  of  the  tumour  in  55  out  of  120  cases 
was  on  the  anterior,  in  26  on  the  posterior,  vaginal  waU ;  in  10  it  was  on  the 
right  and  in  9  on  the  left  side.  According  to  its  position  it  caused  various 
displacements,  cystocele,  rectocele,  dislocation  of  the  urethra  or  chtoris,  etc. 
The  growth  of  these  tumours  is  greatly  accelerated  by  pregnancy.  Histo- 
logically, only  six  of  the  tumom-s  were  purely  fibromatous.  One  tumour 
observed  by  Tedenat  contained  striped  muscular  fibres  in  the  midst  of  the 
nodules  of  connective  tissue  of  the  fibroma." 

John  Phillips  has  recorded  twenty-nine  cases,  nineteen  of  which  were 
mainly  of  a  myomatous  type.f  That  such  tumours  may  undergo  hyaline 
degeneration  and  calcification  is  shown  by  Strassman's  cases.J  The  disease 
may  run  concurrently  in  the  internal  genitaha,  occurring  in  the  ovary  and 
uterus  at  the  same  time  that  they  are  present  in  the  vagina.  Adeno- 
myomata  have  been  met  with  several  times,  and  others  of  a  telangiectatic 
nature.  Malignant  degeneration  is  extremely  rare,  though  sarcomatous 
changes  have  been  recorded,  as  well  as  myxomatous.  They  grow  more 
frequently  in  the  anterior  wall  of  the  vagina,  are  generally  of  a  small  size, 
though  some  instances  have  occurred  in  which  the  growth  assumed  the  size 
of  the  foetal  head.  The  time  of  Hfe  during  which  they  most  frequently 
appear  would  seem  to  be,  according  to  the  statistics  of  Roger  Williams  and 
R.  Smith,§  between  the  ages  of  30  and  40. 

Lipomatous  tumours  are  of  rare  occurrence.  "Williams  mentions  five 
cases,  in  one  of  which  the  tumour,  removed  by  Spencer  Wells,  weighed  two 
pounds.  In  four  out  of  the  five  the  gi'owth  originated  in  the  recto-vaginal 
septum.  A  tumour  of  the  plexiform  neuromatous  type  was  removed  by 
Schmanch.ll 

Carcinoma. — Carcinoma  of  the  vagina,  occurring  as  a  primary 
disease,  is  comparatively  rare — so  much  so,  that  only  some  score  of 
cases  have  been  recorded.  It  occurs  generally  in  women  of  advanced 
life. 

Peterson  records  a  case  ^  at  the  advanced  age  of  84,  and  Maly  one  in 

*  Bevue  de  Gyn.,  torn,  vii.,  part  2 ;  and  Brit.  Gyn.  Jour.,  1903. 

t  Brit.  Med.  Jour.,  vol.  i.,  1899,  p.  262. 

X  Cent./.  Gynalc,  1891,  15,  s.  82.5. 

§  ATner.  Jour.  Obstet.  and  Gyn.,  Feb.,  1902. 

il  Zeits.f.  Geh.  u.  Gyn.,  xlii.,  heft  1.,  1900. 

^  Amer.  Jour.  Obstet.,  1903. 


AFFECTIONS   nF    TUK    VALISA.  8G5 


which  the  carcinoma  occurred  at  the  age  of  67,  where  the  woman  had  for  thirty- 
nine  years  worn  a  ring  pessary,  which  siie  was  in  the  habit  of  herself  removing 
to  cleanse.  Here  the  cancer  occurred  in  a  furrow  corresponding  exactly  to 
tiiat  of  the  ring.     He  states  that  six  similar  cases  have  been  recorded.* 

In  the  greater  portion  of  the  recorded  cases  it  was  the  posterior 
vaginal  wall  that  was  first  affected,  the  disease  spreading  from  thence 
t(t  the  portiu  vaginalis.  The  usual  symptoms  and  signs  of  carcinoma 
are  present.  On  examination,  a  circumscribed,  elevated,  and  hard 
mass,  readily  bleeding,  is  detected,  or,  Avhat  is  more  common,  a 
fungating  tumour,  soft,  and  bleeding  somewhat  profusely.  There  is 
a  vaginal  discharge,  attended  further  on  with  pain  and  vesical  irrita- 
tion. The  rectum  may  become  involved,  and  pain,  with  difficulty 
in  defjecation,  result. 

Operative  Treatment. — The  treatment  consists  in  early  removal 
of  the  mass.  The  incisions  have  to  be  carried  wide  of  the  disease, 
and  going  deeply  beneath  its  base.  The  actual  cautery  is  then 
applied  to  the  raw  surface,  and  the  margins  of  the  wound  brought 
together.  If,  however,  the  disease  be  more  extensive,  and  involve 
the  vaginal  vault  with  the  cervix,  more  radical  operations  must 
then  be  performed,  provided  always  that  it  is  certain  that  the 
disease  has  not  involved  the  subjacent  connective  tissue  to  any 
extent.  Various  proceedings  have  been  recommended,  differing 
in  character  according  as  the  uterus  is  removed  or  not.  In  the 
former  ease,  the  vagina  is  incised  for  its  entire  circumference  con- 
siderably below  the  diseased  portion,  and  then  stripped,  with  the 
fingers  and  scissors,  to  its  attachment  to  the  portio.  The  abdomen 
is  now  opened,  and  the  uterus,  with  the  detached  portion  of  the 
vagina,  removed.  Olshausen  carried  out  a  special  operation,  making 
a  transverse  incision  in  the  perineum  into  the  recto-vaginal  septum, 
and  detaching  the  rectum  and  vagina  as  far  as  the  pouch  of  Douglas, 
The  vagina  is  now  cut  across,  and  all  the  diseased  portion  removed 
with  scissors.  If  the  uterus  must  also  be  removed,  the  pouch  of 
Douglas  is  opened,  and  hysterectomy  performed,  as  in  Doyen's 
method.  When  the  broad  ligaments  have  been  secured  as  far  as 
the  cervix^  the  loosened  and  carcinomatous  vagina  is  cut  through, 
and  is  removed  with  the  uterus.  In  a  case  in  which  the  carcinoma 
involved  the  vaginal  vault  and  outer  surface  of  the  cervix,  Kelly 
operated  by  carrying  an  incision  from  the  end  of  the  sacrum  beside 
the  coccyx  in  a  curved  line  by  the  side  of  the  rectum,  around  the 
rigftt  margin  of  the  anus  and  through  the  perineum  to  the  fourchette. 

*  Ci-tdiaih.f.  Giju.,  190::.  X...  27. 

3   K 


860  DISEASES   OF    WOMEN. 

The  exposed  rectum  was  drawn  with  retractors  towards  the  left,  and 
the  vagina  exposed.  All  the  diseased  portion  was  then  removed, 
including  the  posterior  two-thirds  of  the  upper  portion  of  the  vagina 
and  the  involved  portion  of  the  cervix.  Finally,  the  uterus  was 
fixed  in  retroposition,  and  its  posterior  surface  united  to  the  vaginal 
wall,  thus  filling  in  the  gap  left,  and  leaving  a  short  vaginal  canal. 

Papilloma. — "Walter,  of  Manchester,  has  reported  a  case  of  re- 
curring papilloma  of  the  vagina.  Characteristic  nests  of  cells  were 
found  through  the  fibre- elastic  tissue  removed  at  a  second  operation. 

Primary  Cliorionepithelioma  of  the  Vag-ina.* — Hiibl  has  reported 
a  case  of  primary  chorionepithelioma  of  the  vagina  occurring  in  a 
woman  after  her  confinement,  in  whom  vaginal  haemorrhage  led  to 
the  discovery.  The  uterus  and  adnexa  were  normal.  The  tumour 
was  the  size  of  a  walnut,  and  grew  from  the  posterior  vaginal  wall. 

Microscopical  examination  showed  syncytial  masses  and  Langhan's 
cells.  The  result  of  removal  was  not  favourable,  as  in  similar 
cases  reported  by  Schmit  and  Sehlagenhaufer.  There  was  rapid 
recurrence. 

Sarcoma  of  the  Vagina. — Sarcoma  of  the  vagina  is  a  rare  affection  ; 
up  to  the  date  of  the  publication  of  the  author's  case  in  1902  j  only 
some  thirty-eight  cases  having  been  recorded.  Since  then,  Jellett 
has  published  a  case  in  which  the  disease  involved  the  introitus  for 
its  entire  circumference,  this  area  being  covered  with  irregular 
bosses,  rounded  tumuli,  and  blunt  topped  ridges,  with  a  curious  flap 
in  front  beneath  the  urethral  orifice.  In  my  case,  on  the  first  exami- 
nation I  found  the  vagina  filled  with  a  soft  and  apparently  carcino- 
matous mass,  which  bled  profusely  to  the  touch,  thus  deceiving 
me  as  to  its  nature.  When  the  patient  was  under  anfesthesia  at 
the  time  of  operation,  I  found  the  cervix  uteri  healthy,  but 
concealed  by  the  growth,  which  was  pediculated,  and  attached  to 
the  anterior  vaginal  wall  behind,  the  trigone  of  the  bladder.  I 
secured  the  pedicle  with  a  rope  ecraseur,  and  then  with  a  Bilroth's 
clamp.  The  subjacent  tissue,  from  which  the  ablated  tumour  grew, 
was  cauterized  with  a  Paquelin's  cautery.  The  whole  surface  was 
covered  with  healthy  vaginal  mucous  membrane,  and  the  wound 
healed  by  primary  union.  The  subsequent  history  of  the  case  is 
briefly  told.  The  patient  went  on  well  for  some  five  months,  when 
nodules  appeared  in  the  old  situation,  and  later  on  the  inside  of 
either  lesser  labium.  I  again  operated,  now  removing  the  entire 
anterior  wall  of  the  vagina,  and  exposing  the  bladder,  also  a  portion 
*  Centi-alb.f.  Gyn.,  Dec,  1902.  "  f  Lancet,  vol.  i.  p.  4.39. 


AFFECJ'foXf!   OF    THE    VAdfXA. 


8G7 


of  either  labium.  She  quickly  recovered,  and  had  another  interval 
of  excellent  health.  This,  however,  lasted  for  only  a  few  months, 
and  when  I  next  saw  her  both  labia  had  new  growths,  but  the  skin 
was  not  involved.  A  mass  now  began  to  sprout  from  the  posteritjr 
vaginal  vault,  and  the  cervix  became  involved.  She  was  anxious 
to  have  something  done,  so  I  removed  the  cervix,  and  with  it  all 
the  affected  posterior  vaginal  wall,  at  the  same  time  ablating  the 
affected  portion  of  the  vulva.  She  again  had  a  reprieve  for  some 
time,  but  finally  the  growth  returned  with  increased  virulence,  the 
skin  round  the  vulva  becoming  involved,  with  large  hard  masses. 


Fig.  518.— Spindle-celled  Sarco.ma  of  the  Vagina.    (Author's  Case.) 

The  growth  also  retui'ned  in  the  vagina,  and  she  died  eighteen  months 
fi'om  the  date  of  the  fii'st  operation.  It  was  not  until  towards  the 
end  that  the  glands  of  the  groin  became  enlarged.  Mr.  Targett, 
who  examined  the  primary  growth,  reported  it  to  be  'a  spindle- 
celled  sarcoma  of  the  vagina.  The  surface  is  ulcerated  and  covered 
with  necrotic  material.  Among  the  spindle-cells  there  are  a  few 
larger  polynuclear  cells.' 

In  Jellett's  case,  five  months  after  the  operation,  the  wound  com- 
pletely healed,  and  all  trace  of  granulation  tissue  had  disappeared. 
He  gives  four  tables  bearing  on  the  nature  of  the  sarcoma,  its  relation 


868 


DL^EASES   OF   WOMEX. 


to  the  vaginal  wall,  the  age  of  the  patients  affected,  and  the  result 
after  operation.  Otto  Seitz,*  who  published  his  case  of  spindle- 
celled  sarcoma  in  1900,  collected  all  the  cases  up  to  that  date,  from 
which  it  appeared  that  there  were  only  three  cases  in  which  the 


Fig.  .")40. — Sarcoma  of  the  Vagina.     (H.  Jellett.) 

disease  could  be  said  not  to  have  recurred.  From  Jellett's  table 
the  longest  periods  appear  to  hava  been  one  case  of  Spiegelberg's, 
no  recurrence  after  four  years  ;  one  of  Rubeska's,  no  recurrence 
after  eleven  years  ;  one  of  Morris',  no  recurrence  after  two  and  a 
half  years  ;  one  of  Handheld- Jones',  no  recurrence  after  six  years. f 


Sarcoma  of  the  Vagina  in  a  Child. 

Sanger  met  with  a  case  of  sarcoma  in  a  child  aged  two  years  and  eight 
months,  growing  from  the  anterior  wall,  and  invading  also  the  vulva  and 
puitio.     There  were  several  polypoid  growths.     The  child  died  ten  months 

*  Samml.  hiin.  Vorfrdge,  Leipzig,  1900. 

t  Jour.  Ohsfet.  and  Gyn.  Brit.  Ewp.,  March.  19fti. 


AFFECTIONS   OP   THE    VAGINA. 


860 


after  operation,  and  there  was  general  infiltration  of  the  genito-urinary 
organs,  and  secondarj'  growths  in  the  pelvic  and  lumbar  glands  and  broad 
ligaments.  Schuchardt  and  Frick  met  with  a  case  in  a  child  seven  months 
old,  and  another  at  two  years.  Eoger  Williams  gives  several  instances  of 
polypi  in  the  vagina  of  a  congenital  nature,  and  others  occumng  in  infant 
life.  These  polypoid  growths  are  sometimes  of  a  fibromatous  or  myo-fibro- 
matous  type.     Vaginal  papillomata  have  also  been  noticed  in  young  infants.* 

Vaginal  Fistula. 

I  shall  simply  refer  to  the  varieties  of  fistula  and  their  causes, 
and  conclude  with  a  brief  description  of  the  principal  operations  for 
the  more  frequently  occurring  forms. 

Varieties : 

Vesico- vaginal  fistula. 
Urethro-vaginal  fistula. 
TJrethro-vesico-vaginal  fistula. 
Vesico-utero-vaginal  fistula. 
Recto-vaginal  fistula. 
Perineo-va^inal  fistula. 


Fig.  55(1.— Diagrammatic  Eepresen-  Fig.  551.— Genital  Fistula. 

TATiON  OF    Different   Varieties      vu,    utero-Tesical ;     cvu,    utero-vesico- 
OF  Fistula.     (After  Sinety.)  f  vaginal;   ct,  I'r,  vesico-vaginal ;   uv, 

uretbro-vagiual. 

Other  varieties  are  described  as  uretero-vaginal,  uretero-uterine, 

*  Koger  Williams,  '  Va.irinal  Tumours,  with  Special  Reference  to  Cancer  and 
Sarcoma.'     lOOi. 

t  See  cliiipter  on  Affeftion«  of  tlic  Female  Bladder. 


870 


DISEASES  OF   WOMEN. 


peritoneo- vaginal  (Thomas).     The  names  of  these  fistulas  indicate 
the  organs  involved. 


Fig.  552.    (Bozeman.) 

a,  Urethro-vagiual  fistula  ;  6,  urethro-vesico-vaginal  fistula;  c,  vesico-vagiual 
fistula.     K,  rectum  ;  v,  vagina  ;  b,  bladder. 

Causation : 

Parturition ;  most  frequently  protracted  labour  or  the  improper 
use  of  the  forceps  (an  instrument  more  often  '  sinned  against 
than  sinning ')  in  cases  in  which  it  is  contra-indicated  by  a 
conjugate,  reduced  below  its  working  range,  or  when  mis- 
directed   and   unjustifiable  force   is  employed — very    rarely 


Fig.  553. — Incakcekatios  op  Cervix 
Uteki  in  Bladder.    (Bozeman.) 

Posterior  lip  shown  in  the  fistula 
(diagrammatic  section,  Jth  size). 
Knee-elbow  position. 


■  Fig.  554. — Incakcekation  of  Cervix 
Uteri  in  Eectum.     (Bozeman.) 

Diagrammatic  section,  |th  size.    Knee- 
elbow  position. 


.l/■7•7.■r•/7'^V^"   OF    fill:    r.l^7.V.I.  S7I 

from  the  wcll-tiraed,  not  too  long  delayed,  and  skilled  use  of 

the  instrument. 
Vaginitis. 
Traumatic  causes. 
Phagediena. 
Syphilis. 
Cancer. 
Stone  in  the  liladder. 

Symptoms  and  Physical  Signs. — The  urgency  of  the  symptoms  to 
a  great  extent  depends  on  the  size  and  position  of  the  fistula,  but 
the  principal  ones  are  the  involuntary  passage  of  urine  or  f feces  by 
the  vagina,  and  the  excoriation  of  the  skin  and  soft  parts  in  con- 
sequence of  this  discharge.  The  fistulous  opening  is  generally 
easily  discovered  with  a  Sims'  speculum.  Some  of  the  most  difficult 
to  detect  are  the  very  small  or  slit-like,  and  are  situated  at  the 
summit  of  the  vaginal  canal  in  the  fornix. 

A  minute  opening  may  be  concealed  by  a  vaginal  fold,  and  it 
frequently  requires  very  careful  cleansing  and  searching  with  probe, 
hook,  and  cotton-wool  to  detect  a  small  fistulous  orifice.  If  we  fail 
to  find  the  opening,  the  woman  should  be  placed  in  the  knee-elbow 
position,  and  the  vaginal  canal  well  exposed  with  Sims'  speculum,  or 
retractors.  We  may  inject  the  bladder  or  rectum  with  some  solution 
of  cochineal  or  other  coloured  liquid.  Should  any  cicatricial  bands 
contract  the  vagina,  or  if  there  be  any  atresic  state  of  the  genital 
tract,  the  diagnosis  may  be  still  more  difiicult. 

Fistulfe  differ  in  the  extent  of  tissue  destroyed,  and  the  consequent 
size  of  the  opening,  which  is  sometimes  so  large  that  the  entire 
base  of  the  bladder  is  exposed.  In  a  case  I  had  under  my  care, 
some  years  since,  this  occurred,  and  there  was  also  a  recto-vaginal 
opening  of  sufficient  size  to  admit  the  fingers.  Fistulas  thus  vary 
considerably  in  the  amount  of  cicatricial  tissue  surrounding  the 
edges.  These  "latter  are  constantly  covered  with  mucus  and  phos- 
phatic  deposits,  which  require  to  be  carefully  wiped  away  to  see  the 
shape,  direction,  and  size  of  the  fistula. 

The  dependence  of  vulvitis  and  vaginitis  on  the  presence  of 
small  urinary  fistula  is  not  to  be  forgotten.  The  obstinacy  of 
vaginitis  is  occasionally  explained  by  the  detection  of  a  small 
fistulous  opening,  situated  at  the  junction  of  the  vagina  and  cervix. 

Culling  worth,  in  calling  attention  to  the  occurrence  of  fistula  in  connection 
with  pelvic  suppuration,  points  out  these  special  forms :  (1)  Rectal  fistula, 
due  to  the  rupture  of  a  suppurating  dermoid  into  the  rectum,  six  weeks  after 


872 


DISEASES   OF   WOMEN. 


confinement.  (2)  Vaginal  fistula,  arising  from  pm'ulent  disease  of  the 
adnexa.  (3)  Cervical  fistula,  due  to  ulceration  of  a  suppurating  dermoid 
into  the  cavity  of  the  uterus.  (4)  Vesical  fistula,  arising  from  the  rupture 
into  the  bladder  of  an  abscess  arising  in  connection  vpith  the  adnexa. 

Operation  for  Vaginal  Fistula. 

Preparatory  Treatment.- — ^1.  Sufiicient  time  after  parturition 
should  in  all  cases  be  allowed  to  elapse — six  weeks  to  two  months, 
or  even  more,  if  the  woman's  health  be  not  restored. 

2.  Change  of  air  ;  a  stay  by  the  seaside ;  administration  of  tonics  ; 
warm  vaginal  antiseptic  douches  of  boric  acid,  chinosol  or  lysoform ; 
attention  to  the  character  of  the  urine,  and  the  action  of  the  bowel. 

3.  Any  tension  of  the  sides  of  the  opening  must  be  previously 
attended  to,  and  if  cicatricial  bands  be  present  they  should  be  divided 
by  snipping  them  with  scissors,  a  vaginal  rest  being  inserted  subse- 
quently and  retained  for  some  days.  By  this  operative  step  absorp- 
tion of  cicatricial  tissue  is  secured  and  tension  prevented.  This, 
however,  is  but  rarely  necessary,  as  any  adhesive  bands  can  be  divided 
and  freed  at  the  time  of  operation. 

4.  The  vagina  should  be  douched  with  a  1  in  1000  perchloride  of 
mercury  solution  for  a  few  days  before  operation.     It  is  tamponed 


Fig.  555. — Vesico-vaginal  Fistula  Needles,  Eight  akd  Left. 

with   antiseptic   gauze   twenty-four  hours   before,    and    thoroughly 
sterilized  at  the  time  of  the  operation.     The  rectum  is  emptied  and 


Fig.  556.— -Bryant's  Needles. 


washed  out  with  a  boric  acid  wash  shortly  before  operation.     It  is 
then  wiped  out  with  pledgets  of  gauze  wrung  out  of  perchloride  of 


AFFECT/OXS  OF   THE    VAOIXA. 


873 


mercury  (1  in  3000)  SDlution,  caught  on  a  sponge-holder.  The  exact 
steps  of  any  operation  for  a  vaginal  fistula  will  entirely  depend  on 
its  position,  size,  attachments  to  the  bladder  or  rectum,  as  the  case 
may  be,  or  whether  it  communicates  with  the  uterus,  and  the  situation 
of  the  opening  into  the  uterine  canal. 

Instruments  and  appliances  required  : — 

Leopold's  lateral 

Martin's  large  and  small 

Sims' 

Olhausen's 


retractors. 


Fig.  557. — Emmet's  Lance-headed  Needles. 


Fig.  558. — Vesico-Vaginal  Fistula  Knives,  Stkaight  and  cdrved. 


Fig.  559. — Wike  Oabiuer. 


An  irrigation  retractor. 

Uterine  tenacula. 

Long-handled  double  hooks. 

Perineal  rakes. 

Long  rat-toothed  forceps. 

Scalpels. 

Vesico-vaginal  knives  (straight  and  angular). 

A  few  differently  curved  vesico-vaginal  scissors  ;  one  with  fine 

points. 
Wire-adjuster  and  wire-twister. 
Silver  or  bronze  aluminium  wire. 


874  DISEASES  OF   WOMEN. 

Prepared  catgut. 

Forcipressure  forceps. 

A  few  Kocher's,  Doyen's,  and  Zweifel's  forceps. 

Several  small  sponges — dabs  of  gauze  and  sponge-holders. 

Irrigation  douche. 

Thigh-supports. 

Bozeman's  button-adjuster. 

Short,  straight,  lance-headed,  tubular,  and  curved  needles. 

Needle-holders,  long  and  short. 

Operation  for  Closure  of  Simple  Vesico-Vaginal  Fistula. 

First  Step  :  Denudation  of  the  Edges. — The  patient  is  placed  in 
a  good  light  in  the  dorsal,  knee-elbow,  or  Sims'  position,  according 
to  the  situation  of  the  fistiila.     The  dorsal  I  prefer. 

Three  intelligent  assistants  and  two  nurses  are  required.  One 
assistant  stands  at  each  side  facing  the  operator,  to  assist  with 
retractors,  the  flushing  of  the  surfaces,  holding  of  sutures,  and  to 
control  hfemorrhage.  The  third  with  one  nurse  attends  to  the 
instruments.     The  second  nurse  sees  to  the  dabs,  etc. 

The  first  step  consists  in  freshening  the  edges  of  the  opening  by 

removal  of  a  strip  of  mucous 
membrane  from  its  entire 
circumference,  taking  care  to 
extend  the  incision  well  into 
the  angles  of  the  fistula.  The 
tissue  where  the  knife  trans- 
fixes the  mucous  membrane  is  hooked  up  on  a  tenaculum,  and  put 
on  the  stretch.  By  care,  in  most  cases,  the  ring  of  tissue  desired 
to  be  removed  can  be  taken  away  in  a  single  circular  strip.  The 
mucous  membrane  of  the  bladder  is 'avoided.  The  broader  the  raw 
surface  is  on  the "j vaginal  side,  the  better.  Both  curved  scissors  and 
knife  are  used.  Where  the  edge  of  the  fistula  is  thin  and  bevelled, 
the  operator  has  to  split  the  edge  or  extend  the  denuded  surface  on 
the  vaginal  wall.  Bleeding  is  arrested  by  forcipressure,  hot  irriga- 
tion, pressure,  and  fine  gut  ligature.  If  the  precaution  have  been 
previously  taken  of  dilating  the  vagina  and  rendering  the  uterus 
more  mobile  by  division  of  any  cicatricial  bands,  the  cervix  may  be 
drawn  down  by  a  tenaculum,  and  the  strain  is  thus  taken  off  the 
edges  of  the  fistula. 

Second  Step :  Passing  the  Sutures. — The  operator  has  at  hand  a 


Fig.  560. — Rake  foe  holding  back  Flaps. 


AFFECTIONS  OF  THE    VAGTNA.  875 


blunt  hook,  Emmet's  lance-headed  needles  and  others  variously  curved, 
of  selected  sizes,  threaded  at  the  ends  with  gut.  Emmet  threaded 
his  needles  with  a  loop  of  silk,  for  drawing  the  wire  thread  through. 
The  tissue  is  steadied  with  the  tenaculum  or  a  Kocher's  forceps,  and 
with  the  needle-holder  the  needle  is  entered  at  about  a  quarter  of 
an  inch  from  the  margin  of  the  wound,  and  it  is  pushed  forwards 
until  it  appears  in  the  opening,  when  it  is  seized  and  drawn  through. 
The  vesical  mucous  membrane  is  carefully  avoided.  The  needle  is 
now  entered  at  the  corresponding  point  of  the  opposite  side,  and  the 
needle-point  is  made  to  protrude  on  the  vaginal  surface  at  the  same 
distance  from  the  opposite  margin  of  the  fistula.  The  blunt  hook 
or  tenaculum  is  used  to  make  counter-pressure  by  passing  it  under 
the  needle-point,  while  the  latter  is  pushed  through  any  dense  or 
resisting  tissue.  The  suture  is  now  drawn  through  the  opening, 
and  each  thread  is  taken  charge  of  by  an  assistant. 

If  Emmet's  loop  of  silk  be  resorted  to,  it  has  been  previously  fixed  to  a 
thread  of  silver  wire.  When  the  needle  has  been  passed,  it  is  seized  and 
drawn  through  with  the  silver  wire. 

Sufficient  sutures  are  then  passed,  generally  about  four  or  five  to 
the  inch. 

"When  all  the  sutures  are  passed,  the  operator  again  cleans  the 
wound  of  blood  and  arrests  any  bleeding  from  the  pierced  points. 
If  simple  gut  sutures  be  used 

they  are  tied  off  separately.  .y^^"HlI^fe=jg= —  -  — ^=J^^ 
Silver  or  bronze   aluminium  Yig.  561.— Wire-catch. 

sutures    are    secured    either 

by  twisting,  perforated  shot,      .^^^^^U>i'        '  '  - — ir^-.-^.^/ 

or    Bozeman's    adjuster.      If  j,^^   5G2.-Wire-twistek. 

wire  be  used    adaptation  of 

the  edges  is  secured  by  carefully  drawing  on  the  wire  with  a  wire- 
catch  and  the  use  of  a  wire-twister.  In  twisting  the  wire  care  must 
be  taken  of  the  amount  of  tension  placed  on  the  sutures. 

After-Treatment. — A  careful  nurse  is  given  charge.  The  urine  is 
drawn  off  at  regular  intervals.  The  patient  lies  on  her  back.  The 
greatest  care  is  taken  as  to  the  cleanliness  of  the  glass  catheters 
used,  which  are  kept  sterilized,  as  before  directed  (see  chapter  on 
Asepsis,  also  that  on  the  Ureters).  If  a  retained  catheter  be 
employed,  it  is  withdrawn  three  times  in  the  day  and  washed  freely 
out  by  forcing  a  stream  of  carbolized  water,  or  weak  formalin 
solution,  through  it  with  a  syringe.     Any  stoppage  in  the  How  of 


876 


DISEASES   OF   WOMEN. 


urine  is  at  once  attended  to.  A  second  catheter  should  always  be 
ready  at  hand  to  replace  the  one  removed,  which  is  left  in  an  anti- 
septic solution  until  required. 


Fig.  533. — Bozeman's  Adjusters. 


Fig.  564:. — Showing  Button 
Suture  Closing  Fistula. 

(BOZEMAN.) 


Opium  is  given  to  keep  the  bowel  quiet.  The  vagina  and  bladder 
are  washed  out  daily  with  some  mild  disinfectant.  The  sutures  are 
not  removed  until  the  tenth  day.  The  catheter  is  still  used,  and 
the  woman  is  not  allowed  out  of  bed  until  the  twentieth  day. 

Closure  by  riap-splitting. — Ferguson  *  (Manitoba)  has  performed 
an  operation  for  vesico-vaginal  fistula  on  the  flap-splitting  principle. 

An  incision  is  carried  through  the  vaginal  mucous  membrane  at  a  distance 
of  one-eighth  of  an  inch  from  the  margin  of  the  fistula,  which  completely 
encircles  the  aperture.  The  operator  cautiously  deepens  this  incision  until 
he  reaches  the  lining  membrane  of  the  bladder.  Thus  a  circumferential  flap 
of  the  vaginal  mucosa  is  secured.  By  inverting  this  flap  into  the  bladder,  a 
roof  for  the  raw  surface  is  obtained,  and  is  held  in  this  position  by  a  con- 
tinuous suture  of  fine  chromic  gut,  which  is  inserted  so  as  to  avoid  the  vesical 
wall.  Thus  a  narrow  strip  of  vaginal  mucosa  becomes  part  of  the  lining  of 
the  bladder.  The  ai'tificial  opening  is  now  closed  and  water-tight,  an-d  the 
final  step  of  the  operation  is  the  passage  of  silkworm  gut  sutures  on  the 
vaginal  surface  in  the  ordinary  manner,  the  vesical  mucosa  being  avoided. 

Maclean  suggests  a  plan  for  distending  the  bladder-wall  in  difficult  cases 
of  these  higher  vesico-vaginal  fistulse.  Some  eight  or  ten  inches  of  rubber 
tubing  are  connected  with  an  ordinary  toy  balloon  by  means  of  a  short  glass 
tube.  The  collapsed  balloon  is  passed  through  the  fistula  into  the  bladder, 
and  then  distended  with  five  ounces  of  warm  sterihzed  water.     The  ballooii 


Brit.  Med.  Jour.,  Feb.  24,  1894. 


AFFECTIOXS   nr    TUK    VAC  ISA.  >^71 

is  now  ilnnvii  lirnily  into  tlie  fistula  by  moans  of  tin;  tubing,  wliicii  is  rltunpcd. 
The  freslieninL;'  of  the  fistulnus  opening  is  thus  facilitated. 

Recto- Vaginal  Fistulse. 

These  fistula?  are,  as  I  have  already  said,  often  very  difficult  to 
find.  Their  presence  is  only  discovered  by  the  escape  of  fiecal  gas 
or  matter  into  the  vagina. 

Whenever  the  edges  of  this  fistula  can  be  brought  well  together 
from  the  vaginal  side,  the  operation  of  closing  it  should  be  performed 
from  that  side.  The  woman  is  placed  in  the  lithotomy  position. 
The  rectum  is  thoroughly  emptied  and  washed  out  with  a  warm 
solution  of  boric  acid  and  cleansed  with  1  in  3000  of  mercuric 
perchloride,  and  a  tampon  is  carried  to  the  sigmoid  flexure  so  as  to 
keep  the  part  free  of  fasces  during  the  operation.  The  steps  are 
practically  the  same  as  in  the  vesico-vaginal  procedure ;  but  of  the 
two  the  vaginal  raw  surfaces  must  be  larger.  It  may  be  necessary 
to  attack  the  fistula  from  the  rectal  as  well  as  from  the  vaginal 
side.  If  so,  the  sphincters  should  be  thoroughly  dilated,  and  a 
smaller  duckbill  speculum  used  to  expose  the  fistula.  Sutures  are 
thus  introduced  both  from  the  vaginal  and  rectal  sides.  Goodell 
recommends  the  dissection  of  the  vaginal  mucous  membrane  for 
half  an  inch  from  the  circumference  of  the  fistula,  in  the  form  of  a 
frill,  which  is  inverted  into  the  rectum,  and  the  opening  is  closed 
both  by  rectal  and  vaginal  sutures.  The  bowels  are  locked  for 
fourteen  days  after  the  operation,  though  some  operators  prefer  a 
daily  evacuation.  The  aftex'-care  is  the  same  as  in  other  operations 
of  a  similar  nature. 

Operation  for  Fistula  close  to  the  Anus. — In  two  cases  of  the 
author's  in  which  a  large  fistulous  opening  involved  the  sphincter 
muscle  close  to  the  anus,  it  was  successfully  and  permanently  closed 
by  the  following  operation.  The  vaginal  mucous  membrane  was 
raised,  and  reflected  well  back  for  a  space  of  three-quarters  of  an 
inch  from  the  margin  of  the  opening.  The  rectal  wall  was  next 
separated,  and  the  edges  of  the  aperture  in  it  freshened.  Gut 
sutures  were  then  carried  through  the  muscular  wall  of  the  rectum 
from  one  side  to  the  other,  at  short  distances  apart,  and  through 
the  entire  length  of  the  aperture.  The  edges  of  the  fistula  were 
thus  well  inverted  into  the  rectal  tube.  These  were  tied.  A  purse 
string  suture,  also  of  gut,  was  then  run  round  the  sutured  area  and 
tied.     The  edges  of  the  vaginal  flaps  were  next  freshened,  and  these 


DISEASES   OF   WOMEN. 


■were  brought  together,  covering  the  buried  rectal  sutures.     A  free 
perineorrhaphy  was  next  done, 

Ferguson's  Operation. — As  in  the  case  of  the  vesico-vaginal  plan,  this 
surgeon  obtains  a  circumferential  flap  from  the  vaginal  surface,  extending  to, 
but  not  through,  the  mucous  membrane  of  the  rectum.  The  edge  of  the  flap 
is  seized  with  four  pressure  forceps  inserted  into  the  rectum,  and  a  small  pile- 
clamp  is  applied  to  it ;  the  free  portion  of  the  flap  external  to  the  clamp  is 
burnt  off  with  the  actual  cautery.  Interrupted  sutures  of  silkworm  gut  are 
inserted  and  tied  on  the  vaginal  surface  without  grasping  the  mucous  mem- 
brane of  the  rectum.  The  rectal  clamp  is  then  removed,  a  rectal  tube 
wrapped  with  iodoform  gauze  is  placed  in  the  rectum,  and  the  vagina  is  also 
packed  with  the  same.  Thus  efficient  coaptation  of  an  extensively  bared 
surface  is  obtained,  resulting  in  ready  union.  The  cauterization  lessens  the 
liability  to  septic  infection,  which  is  further  guarded  against  by  the  iodoform 
packs.  The  rectal  tube  is  not  disturbed  for  a  week,  after  which  an  enema  is 
administered  to  secure  an  action  of  the  bowels. 


Vesico-Utero-Vaginal  Fistula. 

In  vesico-utex'O-vaginal  fistula,  where  the  fistulous  opening  is  in 
proximity  to  the  cervix  uteri,  at  the  vaginal  junction,  the  uterus 


Fig.  .565. — Teeatmext  of  Vesico-Uteeine  Fistela  by  Sepea-Pcbic 
Incision.*    (Fkom  Howard  Kelly.    After  V.  Dittel.) 

Vesico-uterine  fold  opened — fistula  freed  from  the  uterus  and  the 
margins  freshened. 

must  be  freed  from  the  bladder,  and  all  cicatricial  tissue  dissected 
*  See  '■  Operative  Gynascology,'  vol.  i.  pp.  330,  331,  by  Howard  Kelly. 


AFFECTIONS   <>F    TIIF    I'.l'-'/.V.I. 


8711 


through,  so  as  to  free  the  uterus  and  render  it  moval)le.  The  shape 
of  the  denuded  surface,  and  the  direction  in  which  the  sutures  are 
passed,  will  depend  upon  the  size,  shape  and  direction  of  the  fistula. 
In  the  case  of  a  small  vesico-uterine  fistula,  we  may  determine 
its  existence  by  the  injection  into  the  bladder  of  coloured  liquid, 
which  will  be  seen  escaping  into  the  cervix.  Should  the  fistula 
unfortunately  be  above  the  cervix,  it  may  be  necessary  to  open  the 
abdomen,  incise  the  utero-vesical  fold  of  peritoneum,  and  separate 
the  bladder  from  the  uterus.  The  openings  in  the  bladder  and 
uterus  are  both  freshened,  and  closed  by  interrupted  silk  sutures. 
Those  passed  in  the  bladder  take  in  the  whole  wall  with  the  exception 


Fig.  .366. — Operation  completed.     (From  Howard  Kelly. 
After  V.  Dittel.) 

of  the  mucous  membi'ane.  The  bladder-opening  is  first  closed. 
Before  closure  of  the  wound,  the  peritoneum  is  restitched  to  the 
uterine  wall.  Such  an  operation  is  fortunately  rarely  called  for. 
Other  surgeons  reach  the  fistula  by  incision  of  the  vaginal  roof, 
carefully  separating  the  bladder  and  uterus  as  far  as  the  fistula, 
which  is  then  closed  by  interrupted  sutures,  as  in  the  last  case,  the 
uterus  not  being  interfered  with.  Iodoform  gauze  is  carried  up 
between  the  uterus  and  the  bladder.  The  vagina  is  loosely 
tamponed  with  the  same.  Fistulse  occurring  lower  down  in  the 
cervix  are  closed  by  free  denudation,  including  the  cei'vical  tissue 
and  the  edges  of    the  vesical   opening.      The  fistulous  track  thus 


880 


DISEASES   OF    WOMEN. 


bared  is  closed  by  silkworm  gut  sutures,  which  are  introduced  from 
the  vaginal  surface  of  the  cervix. 

Bozeman  adopts  an  ingenious  plan  for  previous  stretching  of  the  cicatricial 
tissue   and  the   uterine   ligaments.     He   employs   vulvo-vaginal   dilators   of 

different  sizes,  which  are  worn  after 
division  of  the  cicatricial  hands  and 
adhesions,  and  are  made  of  hard  rubber, 
of  oiled  silk,  or  taffetas  de  soie,  filled 
with  sponge.  He  thus  gradually  dilates 
the  vagina,  and  proceeds  with  division 
of  any  cicatricial  bands.  Tlie  vaginal 
wall  and  the  edges  of  the  fistula  are  thus 
prepared  for  approximation.  He  has 
also  devised  a  special  drainage  support, 
for  draining  off  the  water  directly  from 
the  fistula,  and  so  prevents  any  passage 
of  urine  through  the  vagina  for  some 
time  previous  to  the  operation.  The  drainage  support,  of  which  there  are 
two  kinds,  is  connected  by  a  tube  with  the  urinal.     We  can  bring  about  the 

same  result  by  the  use  of  a  col- 
peurynter  in  the  vagina,  and  gradual 
stretching  of  the  canal,  if  preliminary 
division  of  the  cicatricial  bands  be 
necessary. 

In  the  case  of  very  extensive 
fistulte,  special  operative  procedures 
have  been  undertaken  by  different 
surgeons.  A.  Martin  *  performs  a 
transplantation  operation  from  the 
vaginal  wall,  forming  a  new  floor 
for  the  bladder  with  the  vaginal 
tissue,  and  closing  the  raw  surfaces. 
Dudley,  of  Chicago,!  i^i  ^  case  in 


Fig.  567.— Dilator  in  Position. 


Fig.  568. — Uteeo- Vesical  Drainage 
Support. 
Dimensions  of  instrument :  entire  length, 
4  inches ;  length  of  body,  2  inches ; 
width  of  body,  2  inches ;  thickness  of 
body,  f  of  an  inch;  length  of  dish, 
3  .inches;  superficial  area  of  dish,  -1 
square  inches. 


which  the  anterior  wall  of  the  cervix 
had  sloughed,  making  it  impossible  to  close  the  fissure  in  the  usual  manner, 
denuded  a  strip  of  the  mucous  surface  of  the  bladder  from  side  to  side  for  an 
inch  above  the  posterior  edge  of  the  opening.  The  anterior  margin  of  the 
fistula  was  next  denuded  on  its  vaginal  surface,  and  the  vesical  mucous 
membrane  was  drawn  forward  and  attached  to  it  by  silkworm  gut  sutures. 
Mackenrodt  J  closed  a  large  vesico-vaghial  fistula  by  carrying  an  incision 
across  the  fistula  as  far  as  the  bladder,  exposing  its  entire  base.  He  next 
separated  the  bladder  from  the  vagina  freely,  and,  having  denuded  the  edges 
of  the  opening,  closed  it  by  silkworm  gut  sutures.  Over  this  the  vaginal 
wound  was  closed,  its  edges  having  been  freshened,  and  finally  the  uterus 

*  Zeiisch.f.  Geb.  u.  Gyn.,  No.  19,  p.  394. 
t  Chicago  Med.  Jour,  and  Exam.,  May,  189G. 
X  Centrum,  f.  Gyn.,  No.  1-8.  1894. 


AFFECTIONS   OF   THE    VAGINA. 


881 


was  fixed  in  an  anteflexed  condition  so  as  to  fill  the  gap  and  make  a  base 
against  tlie  newly  closed  opening. 

Freund  adopted  the  plan  refeiTed  to  in  the  text  of  suturing  the  abraded 
uterus  into  the  fistulous  opening  and  to  the  urethra,  which  was  also  involved. 
The  fundus  uteri  was  then  resected,  so  as  to  leave  an  exit  for  the  menstrual 
discharge,  and  in  another  complicated  operation  of  the  same  nature  a  like 
plan  was  adopted,  and  in  both  cases  \\\t\\  a  fair  degree  of  success.  This 
method  of  utilizing  the  lips  of  the  cervix  uteri  for  closing  fistulae  has  been 
adopted  by  different  surgeons.  Trendelenburg,  operating  in  the  inclined 
position,  opened  the  bladder  by  a  transverse  supra-pubic  incision  wide  enough 
to  expose  the  prevesical  space,  and  to  make  an  aperture  in  the  bladder 
sufficient  to  denude  the  edges  of  the  fistula.  This  was  done  by  removing  a 
broad  band  of  tissue  from  the  mucous  membrane  of  the  bladder,  and  a 
narrower  one  from  the  vagina  and  the  cervix.  The  edges  were  brought 
together  by  threading  two  needles  on  one  suture,  and  bringing  its  ends  into 
the  vagina,  where  thev  were  tied.     The  incision  into  the  bladder  was  then 


Figs.  569,  57U. — ^To  illustkate  the  Detachment  of  the  Bladdek  above  and 
ITS  Attachment  to  the  IJTERrs  below.     (Howard  Kelly.) 

closed,  leaving  an  aperture  for  a  T  drainage  tube,  which  was  not  removed 
till  about  the  twelfth  day. 

Howard  Kelly's  plan  *  is  divided  into  four  stages.  The  first  consists  of 
caiTying  a  crescentic  incision  around  the  posterior  two-thirds  of  the  fistula, 
followed  by  detachment  of  the  bladder  from  the  vagina  and  cervix  laterally, 
as  far  as  the  peritoneum  (Fig.  569,  a-x).  The  remaining  anterior  third  of 
the  fistula  (I)  was  then  pared  on  the  vaginal  surface,  the  denudation  being 
cari'ied  down  to,  but  not  including,  the  vesical  and  ureteral  mucosa.  Two 
flexible  urethral  catheters  were  used  to  indicate  and  protect  the  ureters.  The 
last  step  consisted  in  the  union  (a-b)  of  the  posterior  line  of  the  detached 
bladder  to  the  anterior  third  of  the  fistula  on  its  vaginal  surface,  sDkworm  gut 
being  used,  and  the  sutures  being  so  passed  as  to  turn  the  edge  of  the 
muscular  wall  of  the  bladder  up  into  its  cavity,  thus  directing  the  ureteral 
orifices  upwards.     The  vaginal  opening  was  not  closed. 

Vaginal  Enterocele  and  Varicocele. — Various  authorities  have  from  time  to 


Johns  HopMns  Hospital  Bulletin,  Feb.,  1896. 


3   L 


882  DISEASES   OF    WOMEN. 

time  reported  cases  of  vaginal  enterocele,  but  the  complication  is  a  rare  one, 
and  can  only  be  relieved  by  operation.*  Cheron  describes  a  vaginal  varico- 
cele or  a  varix  of  the  recto-vaginal  septum,  associated  with  hsemorrhoids,  and 
causing  pain  in  the  lumbar  region.  He  suggests  treatment  by  upward  massage 
of  the  varix. 

In  a  case  in  which  the  urethra  was  totally  destroyed,  only  a 
mere  strip  being  left,  3  to  5  cms.  broad,  which  bridged  over  the 
meatus,  Berndt  (Stralsund)  first  detached  the  bladder  from  the 
vagina  forming  a  tongue-shaped  flap  from  the  posterior  margin  of 
the  opening  in  the  bladder,  thus  closing  in  the  bladder  wall  and 
creating  a  new  posterior  wall  to  the  torn  urethra.  When  this  flap 
had  healed,  which  it  did  by  first  intention,  a  second  operation 
formed  the  new  urethra  by  making  two  quadrilateral  flaps  from  the 
anterior  vaginal  wall  and  the  adjacent  surface  of  the  labia  minora  ; 
one  flap  Avas  so  turned  that  its  mucosa  covered  the  urethral  gutter, 
while  the  other  was  used  to  cover  the  raw  surface  of  the  first,  thus 
making  a  closed  canal.     The  permanent  result  was  perfect. 

*  Monats.f.  Geb.  u.  Gyn.,  bd.  xvi.,  s.  875. 


CHAPTER    XLIV. 

AFFECTIONS    OF    THE    URETHRA. 

The  examination  and  exploration  of  the  urethra  by  dilatation  have 
been  already  referred  to,  and  in  the  chapter  on  the  bladder  Kelly's 
method  of  exploration  is  described  (p.  895).  Such  an  examination 
\vill  be  found  to  expose  every  portion  of  the  urethral  wall.  The 
affections  of  the  urethra  are  : — 

Congenital  abnormalities.  Angioma. 

Urethritis.  Condyloma 

Prolapse. 

Urethrocele. 

Dilatation. 

Stricture. 

Fistula. 

Urethro-vaginal  abscess. 


Vegetations. 

Caruncle. 

Tumours. 

Carcinoma. 

Polypi. 

Calculus,  and  foreign  bodies  in. 


Congenital  Abnormalities. — The  external  meatus  may  be  dis- 
placed to  the  side,  a  ridge  of  mucous  membrane  projecting  in  the 
middle  line.  The  urethra  itself  may  be  absent  in  whole  or  part ;  or 
the  vagina  and  bladder,  as  in  a  case  of  Langenbeck's,  may  form  a 
common  canal.  Atresia  of  the  urethra  is  very  rare,  but  it  has  been 
recorded.  In  hypospadias  a  portion  of  the  urethra  is  absent,  and 
the  urethra  opens  within  the  vagina,  and  there  may  be  a  common 
urinary  and  vaginal  orifice.  In  epispadias  the  upper  part  of  the 
urethral  wall  is  affected,  and  associated  with  this  malformation 
there  may  be  separation  of  the  labia  and  division  of  the  clitoris,  or 
there  is  more  extensive  arrest  of  development  in  the  upper  wall  of 
the  bladder  or  in  the  symphisis.  As  we  have  already  seen,  the 
position  and  direction  of  the  urethra  are  altered  by  various  com- 
plications, such  as  elongation  of  the  cervix  uteri,  prolapse,  uterine 
tumours,  and  cystocele. 

Urethritis. — Perhaps  the  most  frequent  cause  of  urethritis,  apart 
from  injury,   catheterization,    and  vulvitis,    is  gonorrhcea.     In  the 


884  DISEASES   OF    WOMEN. 

latter  case,  there  is  the  characteristic  everted,  swollen,  and  inflamed 
meatus,  and  round  the  orifice  are  minute  ulcers,  excessively  painful, 
and  constantly  pus  is  seen  filling  the  urethral  orifice.  The  acute 
attack  generally  passes  into  a  chronic  form,  which  may  be  diffuse  or 
circumscinbed.  In  the  former,  small  abscesses  occur,  involving 
Skene's  glands,  and  the  swelling  in  the  anterior  urethra  is  difi'use.* 
In  the  latter,  the  symptoms  are  not  so  severe,  and  there  is  but 
slight  discharge. 

The  treatment  of  chronic  urethritis  is  conducted  on  the  same 
lines  as  those  laid  down  for  vulvitis  and  vaginitis.!  Applications 
of  perchloride  of  mercury  [-—  gr.  to  the  ounce)  or  of  ichthyol  may 
be  made  daily  to  the  urethra.  Any  raw  surfaces  should  be  touched 
with  a  solution  of  nitrate  of  silver  (20  grs.  to  the  ounce). 

Gonosan  in  Gonorrhoeal  Urethritis. — Gonosan  is  a  compound  drug,  being  a 
mixture  of  kawa-kawa  with  oil  of  sandal.  It  is  regarded  as  a  powerful 
antiseptic  in  urethritis  due  to  the  gonococcus.  It  relieves  the  .painful 
symptoms,  increases  the  flow  of  urine,  and  quickly  diminishes  the  amount 
of  the  purulent  discharge.  It  should  be  given  after  meals.  If  pain  in  the 
back  supervene,  it  should  be  discontinued  for  the  time  being. 

Prolapse  of  the  Urethra  is  very  rarely  met  with.  Care  must  be 
taken  not  to  mistake  the  red  and  everted  mucous  membi-ane  for  a 
urethral  growth.  Efforts  at  replacement  should  be  tried  with  the 
parts  thoroughly  cocainized,  or  with  the  patient  under  an  antesthetic. 
Should  these  fail,  the  prolapsed  portion  must  be  removed  either  by 
knife,  scissors,  ligature,  or  galvanic  wire.  Haemorrhage  has  to  be 
controlled  by  a  tampon  and  T-bandage.  Emmet's  plan  of  treating 
prolapse  of  the  urethra  is  to  make  an  opening  in  its  posterior  wall 
similar  to  that  described  in  the  button-hole  operation.  The  pro- 
lapsed tissues  are  drawn  through  the  slit  from  before  backwards. 
A  sound  is  carried  into  the  urethra  to  place  it  on  the  stretch. 
Sutures  are  then  introduced  '  entirely  through  the  flaps  in  the 
urethra,  so  as  to  transfix  the  lining  membrane  along  the  edges  of 
the  wound ;  the  excess  of  tissue  is  then  removed,  and  the  opening 
closed.' 

Acute  Prolapse. — I  recently  had  occasion  to  operate  on  a  ladj',  aged  22,  for 
stenosis  of  the  cervix,  on  whom,  when  a  child,  I  performed  an  operation  both 
by  knife  and  cautery  for  prolapse  of  the  urethra.  The  prolapsed  portion  was 
then  completely  removed,  and  some  hypertrophic  tissue  which  remained  was 

*  See  p.  5,  on  Skene's  Glands.  f  See  chapters  on  the  Vulva  and  Vagina. 


AFFECTIONS  OF   THE    URETERA. 


KSf) 


cauterized.  Further  than  a  little  thickness  of  the  lower  portion  of  the  meatus, 
there  is  now  no  rtMnaius  of  the  alVection.  Arnold  Lea  *  lias  recorded  a  case  of 
acute  prolapse  in  a  patient  aged  35  years.  The  protrusion  occurred  suddenly 
whilst  straining  at  stool.  The  mass  prqjecteil  heyond  the  lesser  labia.  It 
was  rugose,  deeply  congested,  and  almost  black  from  etTused  blood.     There 


Fig.  571. — Prol-'^pse  of  the  Ukethra.     (Arxold  Lea.) 

were  areas  of  greyish  exudation,  and  some  superficial  necrosis.  The  tumour 
was  extremely  sensitive,  and  bled  freely  on  being  touched.  The  genitalia 
were  normal.  Reduction  was  impossible,  and  the  mass  was  amputated,  while 
a  wedge-shaped  piece  was  removed  at  the  lower  part  of  the  urethral  opening 
to  anticipate  any  futiu'e  tendency  to  prolapse. 

Urethrocele. — There  is  a  difference  between  simple  prolapse  of 
the  urethra  and  true  urethrocele  (Emmet),  in  which  latter  affection 
there  is  both  shortening  and  sacculation.  This  sacculation,  Boze- 
man  explains,  is  due  to  contraction  at  or  near  the  meatus,  and  its 
consequent  dilatation  and  bagging  above  the  constriction,  and  the 
retention  of  urine  in  the  urethra.  Emmet,  on  the  other  hand,  asso- 
ciates urethrocele  with  injury  to  the  urethra,  occurring  either  in 
*  Jour.  Ohs.  Gyn.  Brit.  Emp.,  Jan.,  1903. 


886  DISEASES   OF   WOMEN. 

too  rapid  or  too  tedious  a  labour.  Ttie  head  in  its  advance  pushes 
the  loose  mucous  and  submucous  tissues  of  the  upper  part  of  the 
urethra  into  that  portion  below  the  pubic  arch,  and  thus  dilates  it. 
Cicatrization  of  either  end  of  the  urethra  may  occur  with  resulting 
sacculation  of  the  intervening  portion  of  the  canal.  Such  conditions 
of  prolapse  or  true  sacculation  requii'e  careful  examination  on  the 
part  of  the  surgeon,  so  that  he  may  not  confound  the  swelling  with 
a  tumour  or  vesical  enlargement,  or  look  on  it  as  a  mere  secondary 
consequence  of  either  a  rectal  or  uterine  affection. 

Emmet's  Operation. — Emmet  operated  by  introducing  a  block-tin 
sound  into  the  urethra.  With  this  the  prolapsed  tissue  of  the 
vesical  end  of  the  urethra  is  pushed  back  into  the  bladder.  The 
centre  of  the  urethrocele  is  steadied  with  a  tenaculum  while  the 
sound  is  cut  down  upon  with  bent  scissors.  A  fairly  free  incision 
is  made,  avoiding  the  neck  of  the  bladder  or  the  meatus  urethrfe. 
The  excess  of  tissue  entering  into  the  urethrocele  is  now  cut  away, 
but  sufficient  is  left  to  cover  the  sound.  The  sac  is  thus  obliterated. 
The  urethra  is  drawn  out  with  tenacula  to  its  complete  length,  and 
with  fine  interrupted  silk  sutures  the  vaginal  and  urethral  mucous 
membranes  are  brought  together.  The  urethro-vaginal  fistula  thus 
made  is  closed,  when  the  urethra  is  restored  to  nearly  a  normal 
condition. 

Abscess  in  the  Urethro-Vaginal  Septum  (Sub-urethral). 

T.  S.  Cullin  has  accurately  described  the  etiology,  symptoms,  and 
pathology  of  this  affection.* 

Etiology. — After  reviewing  the  anatomy  of  Gartner's  ducts  in 
the  urethro-vaginal  septum,  he  refers  to  the  researches  of  Rieder, 
Doran,  and  others,  proving  that  there  are  remains  of  the  ducts  in 
the  vaginal  septum,  so  also  that  Skej^ie's  tubules,  which  are  situated 
just  within  the  urethral  orifice  on  either  side,  may  be  the  remains 
of  Gartner's  duct  (Kock  and  Bohm).  The  possible  causes  of  the 
saccular  abscess  found  in  the  saccular  distension  of  the  urethro- 
vaginal septum  are  : — 

1.  Congenital  cysts  or  those  occurring  in  the  new-born.  The  latter 
variety  has  been  mentioned  by  Englisch,  who  found  that  in  new-born  children 
small  oblong  cysts  are  occasionally  present  in  the  urethra  near  its  orifice.  He 
suggests  that  these  may  in  after-life  increase  in  size;  and  give  rise  to  the  above 
coudition.f 

*  Jnhni>  Jlopkins  Hospital  BuHetin,  1894. 

t  See  '  Cysts  of  the  Vagina,'  chapter  ou  the  Vagina. 


AFFECTIONS  OF  THE    UliEiniiA.  887 

2.  A  true  urethral  diverticulmn  where  all  the  urethral  coats  take  part.  This 
is  due  to  the  wall  bec-oming  weak  at  one  point  (Lannelongue,  Priestley). 

3.  Accumulation  of  secretions  in  a  urethral  gland. 

4.  Dilatation  of  a  lacuna  of  Morgagni,  probably  due  to  inflammation, 
closure  of  its  orifice,  and  subsequent  distension  with  secretion  (Winckel). 

5.  Dilatation  and  possible  occlusion  of  Skene's  tubules  (BiUim). 

G.  Arrest  of  calculi  in  the  urethra,  with  a  diverticulum  forming  to  accom- 
modate the  same  (Cheron.  Piedpremier). 

7.  Traumatism,  as  a  kick,  or  injuries  during  labour.  Here  an  abrasion  of 
the  mucous  membrane  takes  place,  and  the  urine  gains  access  to  the  small 
pocket,  decomposes,  and  sets  up  an  inflammatory  process  (Duplay). 

8.  A  suppurating  cj'st  situated  in  the  urethro-vaginal  septum,  and  after- 
wards bui-sting  into  the  urethra  'Hermann". 

Symptomatology. — It  may  be  found  in  persons  of  any  age 
(Cheron) — more  likely  between  thirty  and  fifty.  The  symptoms 
are  painful  micturition,  with  discharge  of  ammoniacal  urine  or  pus. 

A  swelling  is  tirst  noticed  in  the  vaginal  vault.  It  is  usually 
situated  in  the  mid-line  about  1  to  2  cms.  behind  the  external  orifice 
of  the  urethra.  The  tumour  varies  in  size  from  a  marble  (Routh) 
to  a  hen's  egg  (Tait),  is  tender  and  fluctuant.  On  pressure  it 
diminishes  in  size,  and  discharge  of  ammoniacal  urine  or  pus  from 
the  urethra  follows,  A  catheter  introduced  along  the  anterior  wall 
of  the  urethra  will  enter  the  bladder  without  difficulty,  and  usually 
clear  urine  escapes.  If  introduced  along  the  urethral  floor  with  its 
point  directed  downward,  it  will  enter  the  sac  cavity.  The  patients 
are  usually  in  good  health  and  give  no  history  of  chills. 

On  changing  from  a  sitting  to  a  standing  posture  there  is  often 
an  escape  of  the  sac  contents,  the  first  intimation  to  the  patient 
being  that  the  clothing  is  moist.  Coition  may  also  cause  a  dis- 
charge of  the  fluid  (Giraud).  In  one  case,  on  pressure  the  contents 
escaped  into  the  bladder  instead  of  passing  out  of  the  urethra 
(Santesson).  "Where  the  discharge  is  irritating  there  is  excoriation 
of  the  external  genitals  and  thighs.  The  sac  opening  in  the 
urethra  will  admit,  as  a  rule,  a  No.  6  catheter.  The  sac  may  have 
smooth  glistening  walls  (Hey),  be  lined  by  squamous  epithelium 
(De  Bary),  or  have  a  ragged  appearance  with  trabeculse  traversing 
its  cavity  (Routh).  Its  contents  are  usually  decomposed  urine  and 
pus  cells,  and  where  the  sac  contains  calculi,  blood  cells  are  also 
found  (Cheron  and  Giraud).  In  one  of  the  cases  where  calculi  were 
present  the  interior  of  the  sac  presented  an  ulcer  at  its  most 
dependent  part,  which  was  probably  due  to  mechanical  injury 
produced  by  the  calculus. 


DISEASES   OF    WOMEN. 


J.  Miller,*  in  recording  three  cases  of  this  affection,  gives  gonorrhoea,  the 
presence  of  urethral  calculus,  retention  and  blood-cysts,  and  parturient  injuries 
as  causes  of  sub-urethral  abscess.  Pressure  along  the  course  of  the  urethra  in 
a  downward  direction  generally  empties  the  sac,  while  palpation  detects  the 
thickened  peri-urethral  swelling,  and  the  urethral  speculum  affords  conclusive 
evidence.  The  urethra  should  be  dilated  and  a  digital  examination  made.  It 
must  not  be  confounded  with  urethrocele.  Exploration  with  a  probe  will 
differentiate  this.  The  most  satisfactory  treatment  is  incision  of  the  abscess. 
Such  agents  as  carbolic  acid,  formahn,  peroxide  of  hydrogen,  may  be  used 
to  disinfect  and  to  arrest  suppuration. 

Treatment. — This  consists  in  the  removal  of  the  redundant  tissue 
in  toto  by  an  elliptical  incision,  then  a  slight  inversion  of  the 
mucous  membrane,  and  closure  by  silk  sutures.  The  catheter 
should  be  passed  three  times  daily  for  three  to  four  days,  and  the 
patient  should  afterwards  be  advised  to  urinate  in  the  genu- 
pectoral  position  for  a  week  longer.  In  introducing  the  catheter, 
care  should  be  taken  to  pass  it  along  the  anterior  urethral  wall. 

FistulSB  of  the  urethra  must  be  closed  by  operation  (see  chapter 
on  the  Vagina,  p.  882). 

Operation  for  New  Formation  of  Urethra  after  its  Destruction. 

Noble  has  recorded  a  case  which,  after  repeated  operations  (his  third 
being  the  fourteenth  effort)  he  successfully  treated  a  large  urethral  gap  which 
followed  an  operation  on  the  vaginal  wall.  In  this  case  the  entire  interior 
wall  of  the  urethra  was  absent,  a  large  fistula,  involving  the  neck  of  the 
bladder,  being  present.  Only. a  strip  of  mucous  membrane,  continuous  with 
the  vesical  wall,  marked  the  situation  of  the  urethra,  while  the  edges  of  the 
fistula  were  cicatricial,  with  lateral  extensive  cicatrices  at  either  side  of  the 
urethral  track.  His  first  effort  to  create  a  urethra  by  a  plastic  operation 
succeeded  so  far  that  the  patient  was  able  to  retain  her  urine  for  from  three 
to  five  hours;  but  a  small  fistula,  arising  from  lateral  traction  due  to  the 
healing  of  the  lateral  incisions,  formed  subsequently,  and  Noble  selected  the 
labium  minus  from  which  to  obtain  the  tissue  for  the  final  operation  to 
elongate  the  urethra  and  bring  the  new  orifice  to  the  clitoris  instead  of  its 
normal  site,  so  as  to  increase  the  retentive  power  of  the  bladder.  The  ulti- 
mate result  of  the  operation  was  that/ by  the  introduction  of  a  small  tampon 
into  the  vagina  to  make  pressure  upon  the  internal  orifice  of  the  urethra,  and 
to  elevate  slightly  the  base  of  the  bladder,  the  patient  could  retain  her  urine 
for  several  hours  during  the  day^  and  slept  soundly  at  night.  The  result 
appears  to  have  been  permanent.f 

Both  venous  angioma  and  vegetations  are  differentiated  from 
urethral  caruncle  by  their  want  of  sensitiveness. 

*  Amer.  Gyn.  Aug.,  1903. 

t  For  a  complete  description  of  Noble's  operation,  see  the  American  Journal 
of  Ohsfetrics,  vol.  xliii.,  No.  2,  1901. 


AFFECTTONF!   OF   THE    UnETHIiA.  88ti 

Polypi  are  readily  removed. 

Condyloma. — Pedunculated  condylomata,  similar  to  those  found 
elsewhere,  grow  at  the  external  meatus.  They  can  be  snipped  off, 
and  the  cautery  a2:>plied. 

Urethral  Caruncle — Situation  and  Nature.— This  growth  is  found 
at  the  oritice  of  tlie  meatus.  In  its  structure  it  consists  of  hyper- 
trophied  hypervascular  papillfe,  surrounded  and  invaded  by  connec- 
tive tissue,  the  papillae  being  generally  covered  with  squamous  and 
stratified  epithelium.  It  is  mostly  in  its  origin  of  an  inflammatory 
nature. 

Pathogeny — Varieties  (Lange). — Lange  *  distinguishes  three  distinct  types 
of  the  disease — simple  gi-anulomata,  papillary  angiomata,  and  simple  angioma. 
The  gi-anuloma  is  characterized  by  an  infiltration  of  round  cells  and  aggrega- 
tion of  capillaries.  To  gonorrhcea  this  inflammatory  form  can  frequently  be 
traced.  The  papillary  angiomata  are  highly  vascular  mucous  polypi  of  the 
papillary  type,  having  an  epithelial  covering  with  papillary  elevations  invaded 
by  connective  tissue  of  a  fibrillary  character.  The  third  variety  has  the  cha- 
racter of  telangiectasis,  delicate  capillary  vessels,  with  thin  walls,  but  so  dilated 
as  to  give  the  tissue  a  cavernous  character.  Cysts  lined  by  a  layer  of  cubicle 
cells  are  not  infrequently  present.  Here  the  epithelium  is  stratified  and 
squamous.  As  to  the  ages  at  which  these  varieties  occur,  granuloma  was  most 
frcjuent  between  twenty  and  forty,  the  papillary  mucous  polypi  after  fifty,  and 
the  telangiectatic  variety  under  forty.  In  middle  life  all  three  varieties  are 
met  with  equally.f 

Symptoms  and  Physical  Signs. — The  patient  generally  consults 
us  for  pain  and  frequency  in  passing  water ;  the  former  at  times  is 
excruciating.  Coitus  is  painful,  and  if  the  case  be  an  aggravated 
one  there  is  pain  in  walking,  and  the  slightest  movement  causes 
distress.  The  woman's  suffering  is  written  on  her  countenance. 
She  is  anxious,  depressed,  nervous,  and  hysterical.  On  making 
an  examination,  the  cause  of  the  suffering  is  at  once  apparent  in 
the  little  raspberry-red  growth  or  growths  which  are  seen,  either 
sprouting  from  or  occluding  the  urethral  orifice.  These  may  be  very 
small  (the  largest  I  have  seen  have  not  exceeded  in  size  a  small 
filbert),  or  they  may  grow  to  the  size  of  a  pigeon's  egg.  The 
characteristic  feature  of  the  affection  is  at  once  demonstrated  by 
the  intense  pain  on  touching  the  growth  with  a  little  cotton-wool 
rolled  on  a  probe.  When  incompletely  anaesthetized  the  woman 
will  still  wince  if  the  tumour  be  manipulated.  This  pain  and 
sensitiveness  is  not  always  present.     I  have  seen  caruncles  which 

*  Zeit^ch.  f.  Gel.  u.  (hjn.,  bd.  xlviii..  heft  1. 

t  Abstract  by  Thomas  Wilson,  Jour.  Oh^.  ami  Gyn.  Brit.  Emp.,  May,  1903. 


890  DISEASES   OF    WOMEX. 

were  not  so  sensitive.  They  may  occur  at  all  periods  of  life,  both 
in  married  and  single.  Goodell  thinks  that  the  pressure  on  the 
urethral  veins  during  the  arrest  of  the  head  in  labour  may  predis- 
pose to  the  occurrence,  but  I  have  seen  carunculse  in  virgins. 
Irritating  discharges  and  habits  of  uncleanliness  are  predisposing 
causes. 

Prognosis. — The  great  tendency  to  recurrence  should  be  remem- 
bered. This  applies  more  to  the  sessile  variety  than  to  the  pe.di- 
culated.  When  multiple,  if  they  be  pediculated,  there  is  the  best 
chance  of  complete  cure. 

Treatment. — There  is  but  one  satisfactory  treatment  for  urethral 
caruncle,  viz.  removal  by  forceps  and  scissors,  and  the  subsequent 


Fig.  572. — Uketheal  Cabuxcle. 

application  of  the  actual  cautery  (Paquelin's),  or  the  galvano-cautery 
knife  or  wire  may  be  used.  We  must  be  prepared  for  smart  bleed- 
ing, which  may  have  to  be  controlled  by  tampon  and  compress.  I 
have  twice  removed  large  growths  of  this  nature  sprouting  from  the 
meatus  and  tilling  the  canal  for  a  short  distance  from  the  orifice. 
The  urethra  was  first  dilated,  and  the  mass  then  carefully  ablated 
for  its  entire  extent.  Bleeding  having  been  arrested  by  forci- 
pressure,  a  flat  electro-cautery  knife  was  carried  over  the  entire 
raw  surface,  up  to  the  healthy  mucous  membrane.  This  latter  was 
then  brought  down,  and  united  by  fine  interrupted  sutures  to  the 
skin,  thus  forming  a  new  orifice.  The  permanent  result  in  both  cases 
was  excellent.     Celloidinzwirn  is  a  preferable  material  to  gut.     If 


AFFFCTWX.^   OF   THF    URETHRA.  891 


an  operation  will  not  be  submitted  to  (which  is  exceptional),  the 
topical  application  of  such  agents  as  carbolic  acid,  nitric  acid,  and 
chromic  acid  may  be  tried  in  order  to  deaden  sensibility. 

Malignant  Disease. — Cases  of  sarcoma,  epithelioma,  melanosis,  and 
rodent  nicer  are  occasionally  met  with.  Temporary  arrest  or  limita- 
tion of  the  disease  is  the  most  we  can  hope  to  effect  by  treatment 
in  these  cases.  The  galvanic  knife,  Paquelin's  cautery,  the  curette, 
and  such  caustics  as  chloride  of  zinc,  lactic  acid,  and  chromic  acid, 
are  among  the  best  methods  of  dealing  with  these  growths. 

Primary  Carcinoma  of  the  Urethra. — Percy,  in  a  critical  review 
of  the  literature  of  this  affection,  could  only  find  nine  undoubted 
cases,  including  those  of  Frankenthal,  published  in  1899.  Percy's 
own  case  was  an  epithelioma  of  transitional  cell  type,  its  epithelium 
harmonizing  with  the  origin  of  the  tumour  from  the  urethra  or 
bladder.  The  four  conditions  which  have  to  be  differentiated  are 
caruncle,  syphilis,  cancer,  and  lupus.  The  last  named  is  never 
primary  in  the  urethra.  The  sensitiveness  and  pain  of  caruncle 
lead  to  early  examination.  The  greatest  difficulty  is  to  distinguish 
between  syphilis  and  malignancy.  Free  and  wide  excision,  with 
removal  of  the  lymphatics,  comprises  the  treatment.* 

Primary  Cancer  of  the  Meatus  TIrinarius — Homesse  f  reported  a  case  of 
primary  carcinoma  of  the  meatus,  in  a  woman  aged  52,  which  followed  a  con- 
tusion caused  by  a  fall,  with  the  legs  separated,  against  the  top  of  a  water- 
pipe.  The  onset  of  the  disease  was  insidious,  and  no  notice  was  taken  of  the 
growth  until  haemorrhage  occurred,  with  pain  on  micturition.  There  was  no 
vidvar  swelling. 

Stricture. 

Stricture  of  the  urethra  may  be  of  congenital  origin,  or  follow — 

Traumatism  in  labour ; 
Cauterization ; 
Gonorrhcea  ; 
Vulvar  lupus  (very  rare). 

Stricture  must  be  treated  either  by  rapid  and  forcible  dilatation 
or  by  gradual  dilatation.  If  the  former  be  practised,  care  must 
be  taken  not  to  injure  the  neck  of  the  bladder  so  as  to  cause 
incontinence.  ISTo  permanent  trouble  has  ever  arisen  in  any  case 
of  urethral  dilatation  in  my  practice.  Cases  of  incontinence  have, 
however,  been  recorded. 

*  Amei:  Jour.  Obs.,  April,  1903.         f  Progres  Medicate,  September  1,  1903. 


892  DISEASES   OF    WOMEN. 

I  prefer  my  metal  uterine  dilators  for  this  purpose  to  any  other. 
They  are  safer  than  Hegar's,  and  the  graduated  bulbous  ends  are 
easier  of  introduction  (p.  82).  For  incontinence  of  urine  with 
pain,  whether  it  be  caused  by  urethral  growths,  extraneous  pressure, 
or  vesical  irritation,  the  greatest  relief  will  be  found  frequently  to 
follow  simple  dilatation  of  the  urethra.  This  can  readily  be  eflfected 
in  the  manner  already  described.  The  practitioner  will  do  well  to 
use  gradual  dilatation,  and  exercise  all  possible  caution  to  avoid 
laceration  of  the  neck  of  the  bladder.  Emmet  insists  on  the  supe- 
riority and  safety  of  his  method  of  exploration  by  incision. 

Should  the  stricture  be  due  to  cicatricial  contraction,  the  urethra 
should  be  thoroughly  cocainized,  and  the  cicatrix  freely  incised,  or 
it  may  be  necessary  (Kelly)  to  resect  the  lower  wall  of  the  urethra 
with  the  cicatrix,  closing  the  wound  with  fine  interrupted  sutures 
and  keeping  a  retained  catheter  in  the  bladder. 

Operations  for  Undue  Dilatation  of  the  TJrethra. — Should  the  urethra  from 
any  cause  be  permanently  dilated,  as  the  result  of  forcible  dilatation  or 
laceration  of  the  external  meatus,  various  plans  have  been  suggested  to  cause 
contraction.  Pawlik  *  draws  the  urethral  orifice  forwards  and  to  the  side,  and 
then  denudes  a  strip  two  centimetres  long  in  the  cleft,  suturing  the  edges  so 
as  to  fix  the  urethra  in  its  new  position.  When  these  sutures  are  removed, 
the  other  side  of  the  urethra  is  drawn  upwards  and  outwards,  and  a  similar 
denudation  is  made.  The  object  is  to  give  the  urethra  a  bend  forwards,  and 
to  flatten  the  posterior  wall  against  the  anterior  by  traction. 

Gersuny,t  having  isolated ,  the  urethral  canal  by  dissection  to  the  neck  of 
the  bladder,  twisted  the  urethra  on  itself,  and  having  thus  formed  a  series  of 
spiral  folds,  secured  it  in  this  form  permanently  by  sutures. 

Frank  contracts  the  in^ethra  by  excision  of  a  portion  of  it  for  the  entire 
length  of  its  posterior  wall  to  within  a  centimetre  of  the  internal  orifice. 
Here,  by  an  elliptical  denudation  of  the  vagina  round  the  neck  of  the  bladder, 
and  the  approximation  of  the  margins  by  sutures,  an  artificial  impediment  to 
the  escape  of  urine  from  the  bladder  is  secured,  which  assists  the  effects  of 
the  excision  of  the  urethra. 

Physiological  Rest  to  the  Bladder. 

Button-hole  of  Emmet. — Emmet  devised  and  advocated  an  operative  pro- 
cedure for  exploration  of  the  urethra,  by  means  of  which  the  entire  canal  can 
be  explored  and  any  local  treatment  apphed.  It  is  safe,  and  can  be  performed 
without  difficulty.  It  does  not  interfere  with  the  control  of  the  urine.  It 
affords  physiological  rest  to  the  bladder  in  cellulitis,  cystitis,  a,nd  other 
cases  of  persistent  bladder  irritability.  He  calls  this  step  '  the  button-hole 
operation.'     It  is  performed  thus:    The  patient  is  placed  on  the  left  side 

^   Wien.Mecl.Wochenschr.,\88^.        "  "{  Gentralh.  fiir  Ghir.,\Sm. 


/■'/■'I'jfT/o.YS  nr  Till-:  ui!i:Tni;A 


808 


uiulor  ;ui  ;ui;ostlietic,  and  a  Sims'  spei'iiliuu  is  iutroducod  su  us  lu  expose 
tlioroughly  tiie  anterior  vaginal  wall.  ICmniet  himself  uses  a  *  button-hole 
scissors,'  the  long  blade  of  which  takes  the  place  of  a  urethral  sound  and  has 
an  aperture  through  which  the  vaginal  blade  passes,  the  latter  being  so  curved 
as  to  avoid  the  urethral  orilice  in  the  incision. 

Under  any  circumstances,  it  is  better  to  introduce  a  sound  of  suillcient  size 
to  stretch  the  urethral  tissues.  A  knife  may  then  be  used.  The  tissues  on  the 
vaginal  side  of  the  urethra  arc  incised  down  to  the  sound,  midway  between 
the  urethral  orifice  and  the  neck  of  the  bladder:  this  latter  must  be  carefully 
avoided.  The  line  on  the  vaginal  side  is  a  third  more  than  that  on  the 
urethral,  this  extension  being  mainly  on  the  vesical  wide  ol  tli(!  incision. 
Through  the  incision  thus  made 
we  can  explore  the  urethra  and 
the  entrance  to  the  bladder. 
Emmet  employed  this  method 
ibr  exploration,  but  such  an  in- 
cision, for  this  object  solely,  will 
be  rarely  necessary.  Should  it 
be  so,  after  exploration,  we  close 
the  wound  immediately  by  in- 
serting sutures,  which  include 
the  urethral  raucous  membrane, 
and  pass  from  one  side  of  the 
wound  to  the  other,  the  lips 
being  well  everted  by  a  tena- 
culum. The  patient  is  kept  in 
bed  for  over  a  week,  and  the 
passage  of  a  catheter  is  avoided 
if  possible. 

On  the  other  hand,  if  our  ob- 
ject be  to  maintain  the  patency 
of  the  opening,  so  as  to  secure 
physiological  rest  for  the  blad- 
der, the  edges  of  Ihe  urethral 
mucous  membrane  are  united  to 
the  vaginal  surface  by  means  of 
interrupted  sutures  of  silkworm  gut  or  carbolized  silk.  The  edge  of  the 
urethral  tissue  is  drawn  out  and  covered  by  the  vaginal  membrane,  and  both 
are  neatly  united,  and  granulation,  if  possible,  prevented.  The  patient  is  kept 
in  bed,  the  parts  are  douched  with  warm  carbolized  water,  and  after  the  douche 
or  sponging,  the  wound  is  smeared  wath  some  mild  astringent  ointment  or 
salve;  this  treatment  is  continued  for  some  time.  If  the  opening  be  no 
longer  indicated,  it  is  closed  in  the  same  manner  as  a  vesico-vagiual  fistula. 


Fig.  573.— But- 

TOX-HOLE  SciSSOltS. 


Fig.  574. — Emmet's 
buttox-hole  openixg. 


Calculi. — Calculi  in  the  urethra  may  be  dealt  with  either  by 
clilatatiod  with  forceps,  or  by  a  vaginal  incision,  or,  if  they  be  soft, 
they  may  be  crushed  and  the  debris  removed. 


CHAPTER  XLV. 


AFFECTIONS  OF  THE  FEMALE  BLADDER. 


Malformations. 

Displacements. 

Hypersemia. 

Fistula. 

Prolapse. 

Calculus. 

Foreign  bodies  in. 


Cystitis. 

acute    .    simple,  catarrhal,  septic. 

{traumatic,  post-operative, 
sonorrhceal. 
tubercular. 
puerperal. 


Tumours : — 


Papilloma. 

Myoma  and  fibromyoma. 

Adenoma. 

Myxoma. 


Sarcoma. 

Carcinoma. 

Dermoid. 


The  reference  to  any  of  these  vesical  affections  in  this  work  must 
necessarily  be  brief.  Still,  in  any  work  on  gynaecology  it  is  essential 
to  include  a  description  not  only  of  modern  methods  of  diagnosis, 
but  also  of  the  more  commonly  occuiTing  diseases  which  the  surgeon 
is  daily  brought  into  contact  with,  and  to  endeavour  to  succinctly 
summarize  their  treatment. 

Examination  of  the  Bladder.— The  female  bladder  may  be 
examined  by  any  of  the  following  methods  : — 

(a)  X  Rays.- — The  view  is  universal  that  in  every  case  of  sus- 
picion or  doubt  as  to  the  presence  of  a  calculus  or  foreign  body  in 
the  bladder,  ureter,  or  kidney,  the  Rontgen  ray  should  be  always 
availed  of,  and  a  radiograph  obtained.  I  am  indebted  to  Mr. 
Shenton  for  the  three  illustrations  on  the  adjoining  plate. 

Shenton  *  gives  the  following  results  in  200  suspected  cases  of  the  X-ray 
examination : — 

'  Cases  examined,  200. 

'  Cases  in  which  the  rays  and  surgeon  discovered  calculi,  28. 

*  Guy's  Hospital  Reports,  vol.  Ivi. 


PLATES   CXVITI.,    CXIX ,   CXX. 


Calculus    in 

TiiK  Eight 

Kidney. 

(8HKNT0X.) 


Calculus    in 
THE  Right 

Ureter. 
(Shenton.) 


Two  Calculi 

IN    THE 

Bladder. 
(Shenton.) 


[To  face  p.  894. 


I 


AFFECTIONS  OF    THE   FEMALE    BLADDER.  895 

*  Cases  in  which  surgeon  found  calculi  and  the  rays  did  not,  H. 

'  Cases  stated  not  to  have  calculi  by  the  rays,  and  operated  on  witii  negative 
results,  11. 

'  Number  of  cases  in  which  the  rays  detected  calculi,  but  sur^'con  did  not,  2. 

'  Therefore,  the  number  of  cases  in  which  the  result  obtained  by  the  rays 
has  been  proved  to  be  correct  amount  to  39. 

'  The  instances  in  which  they  have  been  proved  wrong  are  8.  The  153 
remaining  cases  are  doubtful,  as  they  have  not  been  operated  upon,  but  in 
most  instances  the  negative  evidence  of  the  rays  has  been  confirmed  hy 
subsequent  history. 

'  It  will  be  seen,  therefore,  that  the  positive  evidence  is  almost  perfectly 
reliable,  the  negative  not  absolutely  so,  but  that  it  should  be  allowed  to  have 
weight  when  considered  with  other  symptoms. 

'  The  errors  occurred  in  stout  people  and  in  those  who  presented  abnormal 
opacity  to  the  rays,  or  in  cases  where  the  stones  were  very  small,  or  where 
composed  of  uric  acid  or  urates  without  admixture  of  more  opaque  salts.' 

(b)  Percussion. — The  over-distended  bladder  can  be  detected  by 
careful  percussion. 

(c)  Palpation. — It  may  be  palpated  bi-manually  with  the  index- 
tinger  of  the  left  hand  in  the  vagina,  and  the  right  hand  placed 
supra-pubicaUy.  Palpation  is  assisted  and  bi-manual  examination 
is  best  conducted  by  the  emptying  of  the  bladder  beforehand.  It 
may  be  further  facilitated  by  placing  the  patient  in  the  knee-elbow 
position.  A  tumour  or  stone  in  the  region  of  the  neck  of  the  viscus 
may  thus  be  felt. 

{d)  By  the  Sound. — With  a  sound  in  the  uterus  and  another  in 
the  bladder,  the  size  and  situation  of  a  tumour — as,  for  example,  a 
displaced  ovary  or  dermoid  cyst — may  be  determined  on. 

(e)  Dilatation  of  Urethra. — In  the  absence  of  the  cystoscope,  the 
urethi-a  may  be  dilated  with  graduated  dilators  until  the  linger  can 
be  passed,  and  the  neck  of  the  bladder,  as  far  as  the  ureteral  line, 
explored.  "With  the  finger  of  the  i-ight  hand  in  the  bladder,  and 
the  left  in  the  vagina,  circumscribed  growths  may  be  felt  between 
the  two.  This  operation  has  to  be  cautiously  conducted  under  an 
anaesthetic,  and  the  maximum  degree  of  dilatation  should  be  arrived 
at  slowly. 

Kelly  says,  '  The  time  has  for  ever  gone  '  for  this  procedure.  This  may 
be  so  for  the  skilled  cystoscopist ;  but  it  is  not  applicable  to  many  surgeons 
who  have  not  this  appliance  or  Kelly's  instruments,  and  who  have  to  aid 
their  diagnosis  by  such  an  exploration  as  that  mentioned  in  the  text. 

(/)  Cystoscopy. — The  cystoscope  of  Nitze  or  that  of  Kolischer 
(Fig.  553)   may   be   used.       This   examination  requii-es  care   in  its 


AFFECr/OXS   OF    THE   FEMALE    r.LADDER. 


8'.»7 


application,  and  practice  both  on  the  living  and  dead  subjects  and 
on  artificial  bladders. 

{g)  Incision  through  the  Vagina  and  Urethral  Dilatation.— 
Emmet's  plan,  by  dilatation  of  the  urethra  and  incision  through 
the  vagina,  has  been 
already  referred  to. 
It  is,  perhaps,  the 
most  preferable  me- 
thod to  adopt  ill 
certain  cases  of  tu- 
mour of  the  neck  of 
the  bladder  which 
has  to  be  removed 
by  operation. 

(/i)  Howard 
Kelly's  Method  of 
Direct  Examina- 
tion of  the  Female 
Bladder.  —  Howard 
Kelly's  method  of  direct  examination  of  the  female  bladder  and 


Fig.  576. — Dorsal  Position  of  the  Body  for  Ex- 

PLORATIOX    OP    THE    BLADDER     AND    URETER     IN 

Howard  Kelly's  Method. 


Fig.  577. — Patient  supported  with  Kelly's  Suspenders  in  the  Knee- 
elbow  Position  for  either  Cystoscopy  or  Proctoscopy. 


ureters  with  elevated  pelvis,  and  catheterization  of  the  ureters,  is 

3   M 


898  DISEASES   OF    WOMEN. 

uow  well  known.  The  importance  to  the  gynaecologist  of  his  exact 
ureteral  examination  cannot  be  over-estimated.  I  have  already, 
in  discussing  the  surgical  treatment  of  uterine  fibromata,  referred 
to  the  secondary  renal  effects  which  follow,  both  from  pelvic  in- 
flammations and  tumours  pressing  upon  and  involving  the  ureters, 
as  also  their  implication  during  the  different  operations  for  hysterec- 
tomy, and  to  the  anatomy  of  the  ureters  and  their  course.  The 
fact  that  they  are  accessible  to  exploration  was  demonstrated  by 
Kelly.  For  the  landmarks  for  finding  the  orifice  of  the  ureter  and 
its  palpation,  the  reader  should  refer  to  pp.  46-50.* 

In  using  Kelly's  cystoscope,  either  the  dorsal  or  knee-breast  posi- 
tion may  be  selected.  Perhaps  the  latter  is,  on  the  whole,  the  one 
now  more  generally  availed  of,  but  much  may  depend  on  the  nature 
of  the  case,  the  form  of  growth  or  the  position  of  the  diseased  area, 
or  some  displacement  of  the  bladder  by  extra-vesical  effusions  or 
growths. 

Details  of  Method. 

'  The  genu-facial  position  is  indispensable  in  those  cases  in  which,  owing 
to  disease,  the  bladder  will  not  balloon  out  in  ordinary  posture ;  but  Kelly 
frequently  succeeded  in  the  dorsal  and  left  semi-prone  positions  if  the  pelvis 
were  moderately  elevated.' 


Fig.  578. — Kelly's  Urethral  Calibrator. 
The  lines  indicate  the  diameter  in  millimetres. 

Kelly  '  exposes  the  whole  inner  surface  of  the  bladder,  and  the  ureteral 
orifices,  to  a  direct  inspection  without  any  intervening  fenestra  or  mirror.' 
By  this  method,  he  says  '  any  gynaecologist,  after  a  little  practice,  should 
be  able  in  almost  every  case  to  catheterize  either  ureter  within  a  few  seconds 
after  the  introduction  of  the  speculum.  The  bladder  exposed  in  this  way 
may  be  inspected  with  as  much  ease  and  more  directly  than  the  larynx,  the 
posterior  nares,  or  the  fundus  oculi. 

'  The  following  instruments  and  accessories  are  required  for  the  examina- 
tion :  a  female  catheter ;  a  series  of  urethral  dilators  ;  a  series  of  specula  with 
obturators ;  a  common  head  mirror,  and  a  lamp,  Argand  burner,  or  electric 
light ;  long  delicate  mouse-toothed  forceps  ;  suction  apparatus  for  completely 
emptying  the  bladder ;  ureteral  searcher ;  ureteral  catheter  without  a  handle  ; 
several  bran  bags  or  an  inclined  plane  for  elevating  the  pelvis. 

*  Also  chapter  on  Ureters. 


AFFECTIONS   OF   THE   FEMALE    ltLAI>l>KI{. 


899 


*  The  bladder  is  first  emptied  as  completely  as  possible  by  the  catheter.     A 

resicluum  of  from  one  to  several  teaspoonfuls  of  urine  always  remains,  even 
though  the  bladder  be  evacuated  with  the  patient  in  a  standing  posture.  In 
order  to  deterniino  the  proper  dilator  to  Iicgiu  with,  I  calibrate  the  meatus 
urinarins  oxternus  by  means  of  a  slender  nu-tal  cone  10  centimetres  long, 
marked  in  a  graduated  scale  from  its  point,  '2  millimetres,  to  its  upper  end, 
20  millimetres  in  diameter.  The  calibrator  is  pushed  into  the  urethra  as  far 
as  it  will  readily  go,  and  the  marking  at  the  meatus  externus  noted.  A 
dilator  of  the  diameter  indicated  by  the  calibrator  is  then  passed  tlirough  the 
m-ethra  by  holding  the  handle  at  first  well  above  the  level  of  the  external 
meatus,  upon  which  the  point  rests,  and  carrying  the  dilator  on  through  the 
urethra  and  into  tlie  bladder  by  a  gentle  sweeping  curve  of  the  band  down- 
ward and  inward  toward  the  urethra.' 

Kelly  uses  sigmoid-shaped  conical  dilators  graduated  in  millimetres  like  the 
specula,  and  flattened  in  the  centre  for  the  purpose  of  grasping.  lie  estimates 
the  urethral  calibre  at  2  centimetres  in  diameter  and  6  in  circumference. 


.579. bPECULUM    AND    OUTUKATOE. 

Two-thirds  natural  size. 


'  By  introdncing  the  dilators  as  they  occur  in  the  series,  the  average  female 
urethra  can  easily  be  dilated,  up  to  12  millimetres  in  diameter  with  only  a 
slight  external  rupture.'  He  has  never  seen  a  tear  of  more  than  2  or  3 
milHmetres  in  length  and  from  1  to  IJ  in  depth. 

I  do  not  here  figure  the  special  dilators  of  Kelly.  Those  figured  at  p.  82 
will  answer  every  purpose. 

'  As  soon  as  a  dilatation  of  from  12  to  15  millimetres  is  reached,  a  speculum 
of  the  same  diameter  as  the  last  dilator  is  introduced,  and  its  obturator 
removed.     Boro-glyceride  is  the  best  lubricant. 

'  The  hips  of  the  patient  are  now  elevated  on  the  cushions,  or  on  a  short 
inclined  plane,  26  or  30,  or  even  40,  centimetres  (8  to  12  or  IG  inches)  above 
the  level  of  the  table  (Fig.  576),  that  is  if  the  dorsal  position  be  chosen,  or 
she  is  placed  in  the  Icnee-breast  position  and  supported  on  it. 

'  There  are  sixteen  specula  (Figs.  579,  580),  varying  from  5  to  20  milli- 
metres in  diameter,  the  successive  sizes  increasing  by  1  millimetre.  The 
specula  are  cylindrical,  9^  centimetres  long,  and  each  is  provided  with  a 
conical    mouth   to    assist   in   reflecting   the   light   into    the    bladder.     Each 


900 


DISEASES  OF    WOMEN. 


speculum  is  fitted  with  an  obturator  (Figs.  579,  580).     The  calibre  is  marked 
in  millimetres  on  a  little  handle  at  the  side  of  the  speculum. 

'  The  examiner  now  puts  on  the  head  mirror  and  prepares  to  inspect  the 
bladder.  An  electric  drop  light,  an  Argand  burner,  a  lamp,  or  a  candle  in  a 
dark  I'oom,  is  held  close  to  the  patient's  symphysis  pubis  so  that  the  light  can 
be  easily  caught  by  the  head  mirror  and  reflected  into  the  bladder.     A  good 

direct  light  from  a  window  will  also  sulfice. 
'  Upon   withdrawing   the    obturator,    the 
pelvis  being  elevated,  the  bladder  becomes 
distended  with  air,  and  by  properly  direct- 


7J 


ing  the  reflected  light  all  parts  of  its  interior  are   accessible   to  a  direct 
inspection. 

'  If  a  pool  of  urine  remain  in  the  bladder,  it  should  be  withdrawn  by  means 
of  a  simple  suction  apparatus  (Fig.  581).  If  there  be  a  residuum  of  not  more 
than  2  or  3  cubic  centimetres,  it  can  easily  be  removed  by  little  balls  of 
absorbent  cotton  grasped  with  long,  deHcate  mouse-toothed  forceps,  the  ieeth 
of  which  are  slightly  recurved.  The  facility  with  which  foreign  bodies  are 
removed  from  the  bladder  by  this  method  can  be  demonstrated  by  dropping 


AFFECTIONS   OF  THE   FEMALE   BLADDEB. 


oni 


a  pledget  of  cotton  into  the  bladder — it  can  be  seen  A\ntb  tbe  utmost  ease, 
picked  up,  and  removed  without  difficulty. 

'  The  posterior  wall  of  the  air-distended  bladder  lies  2  to  5  centimetres 
distant  from  the  anterior  wall,  and  over  this  white  background,  which  first 
presents  itself  to  the  eye  of  the  observer,  is  visible  a  beautiful  network  of 
branching  and  anastomosing  vessels.  The  veins  accompanjnng  the  arteries 
are  easily  distinguished  by  their  dark  colour.  The  larger  vessels  evidently 
come  to  the  surface  from  the  deeper  layers  of  the  bladder,  when  they  branch 
stellately,  divide,  and  anastomose. 

'  To  introduce  the  speculum,  it  is  grasped  as  shown  in  Fig.  582,  and  the 
obturator  is  kept  from  slipping  back  into  the  cylinder  by  a  decided  pressiu'e 
with  the  thumb,  continued  until  the  end  has  entered  the  bladder.  The  urethra, 
wiped  clean  with  a  boric-acid  solution, 
is  exposed  by  an  assistant  holding  the 
buttocks  and  the  labia  well  apart,  while 
the  point  of  the  speculum,  coated  with 
the  boro-glyceride  solution,  is  applied 
to  the  urethral  orifice,  and  pushed 
through  the  uretkra  into  the  bladder 
with  a  gentle  sweep  around  the  pubic 
arch.  The  handle  of  the  speculum  is 
now  firmly  grasped,  while  the  obturator 
is  withdrawn  with  a  slight  rotary  mo- 
tion. If  the  internal  urethral  orifice 
is  drawn  well  into  the  pelvis  by  the 
posture,  the  urethra  is  so  much  curved 
that  there  is  danger  of  injuring  it  by 
pushing  the  speculum  hard  against  its 
posterior  wall;  this  must  be  avoided 
by  introducing  the  speculum  in  a  de- 
cided curve.  The  moment  the  ob- 
turator is  taken  out  the  air  rushes  in 
and  the  bladder  is  dilated  and  ready 
for  the  inspection. 

'  If  the  bladder  does  not  expand  in 
this  way  the  examiner  will  usually  find 
that  the  patient  has  assumed  a  faulty  position,  and  as  soon  as  this  is  corrected 
the  expansion  occurs. 

'  If  the  patient  is  in  the  knee-breast  position  the  examiner  sits  on  a  stool 
with  his  eyes  a  little  below  the  level  of  the  urethra,  gi'asping  the  handle  of 
the  speculum,  which  is  turned  upward,  and  he  should  wear  the  head  mirror 
over  the  same  eye  he  uses  at  the  microscope. 

'  The  assistant  now  holds  the  electric  droplight  close  to  the  end  of  the 
sacrum,  which  is  protected  from  the  heat  by  one  or  two  towels,  and  the  lower 
margin  of  the  head  mirror  is  drawn  away  from  the  face  and  turned  until  the 
reflected  hght  spot  falls  within  the  bladder.' 

By  dropping  the  handle  of  the  speculum  decidedly,  its  inner  end  is  raised, 
and  the  vault  or  summit  of  the  bladder  is  brought  into  view,  and  every  part 


Fig.  582.  —  Showing  the  Use  of 
TJketebal  Seaecher  before  Ca- 
theterization IX  THE  Dorsal  Po- 
sition. 

The  light  is  thrown  on  the  miiTor  by 
an  electric  lamp  held  by  the  as- 
sistant. 


902  DISEASES   OF   WOMEN. 

of  the  organ  inspected  by  moving  the  end  from  side  to  side.  By  elevating  the 
handle  decidedly,  the  floor  of  the  bladder  is  examined  in  the  same  way,  and 
then  by  moving  it  to  the  right,  the  right  and  left  walls  come  into  view. 

Kelly  insists  on  the  extreme  care  with  which  catheterization 
must  be  carried  out,  '  in  its  aseptic  technique  equal  to  that  of  any 
surgical  procedure,'  This  refers  to  the  sterilization  of  the  instru- 
ments and  the  avoidance  of  contamination,  either  with  the  appliances 
or  the  hands  of  the  examiner  or  his  assistant.* 

Malformations. 

Cases  have  been  recorded  of  the  congenital  defect  known  as  double 
bladder.  Cattier  in  the  seventeenth,  and  Gerard  Blasius  in  the 
eighteenth  century,  met  with  cases  of  this  anomalous  condition, 
but  these,  with  those  reported  by  Allan  Smith  of  Baltimore,  and 
Fiith  of  Metz,  in  1878  and  1894,  occurred  in  the  male  sex. 
Howard  Kelly  says  that  he  found  two  cases  of  loculate  bladder, 
that  is,  a  bladder  with  diverticula  or  pockets,  mistaken  for 
supernumerary  bladders  by  earlier  observers.f 

Exstrophy  of  the  bladder  is  rarely  met  with  in  the  female  sex. 
In  this  condition  there  is  a  defect  of  fusion  in  the  abdominal 
laminse,  and  in  consequence  there  is  an  opening  in  the  abdominal 
wall,  with  a  fissure  in  the  anterior  wall  of  the  bladder,  or  a  still 
larger  defect  in  it  which  is  sometimes  associated  with  a  cleft  in,  or 
absence  of,  the  symphysis  pubis.  Such  exstrophy  has  as  its  conse- 
quence a  protrusion  of  the  mucous  membrane,  which  has  more  or 
less  of  a  fleshy  granulating  or  indurated  appearance.  It  may  be 
associated  with  other  congenital  defects  in  the  genital  organs. 

A  transplantation  operation  is  here  indicated,  the  number,  size, 
and  shape  of  the  skin  flaps  depending  upon  the  size  and  character 
of  the  opening. 

A  case  was  sent  me  by  the  late  Martin  Brown,  of  Exeter.  A  young  woman, 
aged  21,  had  never  retained  her  urine.  The  urethra  (practically  the  neck  of 
the  bladder)  was  very  large,  admitting  the  forefinger,  and  was  about  one  inch 
in  length.  The  ureters  opened  immediately  into  it.  The  bladder  was  con- 
tracted to  the  size  of  a  few  inches  in  either  diameter.  Its  mucous  coat  was 
quite  smooth.  The  large  urethral  orifice  was  placed  higli  up  at  the  summit 
of  the  vulva,  which  was  abnoi-mal  in  the  position  of  both  its  larger  and  smaller 
lips.  The  vaginal  canal  otherwise  was  normal.  The  girl  had  an  offer  of 
marriage.  An  endeavour  was  made  to  create  a  urethral  orifice  by  transplant- 
ing the  labia  and  nympha3  towards  the  mesian  line,  and  thus  to  elongate  the 

*  For  Catheterization  of  the  Ureters,  see  chapter  on  Ureters. 
t  Howard  Kelly, '  Operative  Gynsecology,'  vol.  1.  p.  317. 


AFFECTIONS  OF  THE  FEMALE  BLADDEIi.  003 


urethral  canal.  There  was  a  partial  success,  but  it  was  not  permanent, 
though  the  cosmetic  effect  was  all  that  could  be  desired.  Thfe  urine  secreted 
from  the  kidney  immediately  crusted  on  the  self-retained  catheter,  and 
commonly  dried  in  powder  on  the  clothes.  Some  of  the  urine  was  analyzed. 
It  was  resolved  into  calcium  phosphate,  sodio-ammonium  phosphate,  and 
ammonio-magnesium  phosphate — practically,  earthy  and  alkaline  phosphates. 
It  was  surcharged  with  ammonium  carbonate,  probably  produced  by  the 
decomposition  of  urea.  It  also  contained  an  araylotic  ferment  and  traces  of 
pepton,  phenol,  and  biliary  excreta.  A  portion  of  an  elastic  catheter  mace- 
rated in  some  of  this  urine  for  three  days  was  bleached,  a  white  deposit 
(phosphatic)  of  earthy  salts  being  deposited  upon  the  submerged  surfaces. 
At  the  same  time  a  small  quantity  of  sulphur  was  set  free  from  the  catheter. 

Alterations  from  the  normal  position  of  the  bladder,  with 
encroachment  upon  its  walls,  and  consequent  distension,  or  its 
partial  displacement,  are  generally  due  to  effusions  into  the  pelvic 
cavity,  tumours  of  the  uterus,  or  prolapse.* 

Hypergemia  of  the  Trigone. — Irritation  of  the  neck  of  the  bladder, 
in  the  region  of  the  ureters,  is  a  commonly  recognized  condition.  A 
scalding  sensation  in  passing  water,  frequency  in  micturition,  with 
pain,  are  the  prominent  symptoms. 

Irritation  caused  by  Carbolic  Acid. — In  the  case  of  a  patient  on  whom  I 
once  operated  for  carcinoma  of  the  cervix,  I  found  that  any  application  of 
carbolic  acid  in  the  weakest  solution  in  the  vagina,  or  even  an  examination 
with  carbohzed  vaseline  on  the  finger,  immediately  produced  intense  vesical 
irritation.  This  was  accompanied  by  symptoms  of  vaginitis,  with  heat  and 
swelling  of  the  vulva. 

Excessive  acidity  of  the  urine,  errors  of  diet,  cold  contracted  from 
chill,  after  pelvic  operations,  especially  for  haemorrhoids,  the  passage 
of  the  catheter,  or  rudeness  in  coitus,  are  some  of  the  most  frequent 
sources  of  this  vesical  irritation. 

The  urethra  is  iatensely  sensitive  to  the  catheter,  and  its  orifice 
is  sometimes  found  red  and  slightly  swollen.  Howard  Kelly  has 
examined  by  his  method  patients  suffering  from  this  condition,  and 
has  found  the  entu-e  bladder  sound  with  the  exception  of  the  trigone 
area. 

I  had  a  most  obstinate  case  in  which  an  enlarged  ovary  was  removed,  and 
the  uterus  was  ventro-suspended,  for  cystic  irritation  lasting  from  cliildhood. 
The  operation  did  little  good.  The  cystoscope  showed  enlarged  veins  in  the 
neighbourhood  of  the  trigone  and  some  hypertemia — nothing  else  could  be 
discovered.  In  this  case  the  patient  complained  of  acute  pain  in  the  neck 
of  the  bladder,  occurring  occasionally,  of  a  neuralgic  nature.     Before  I  saw 

*  See  chapters  on  Pyo-salpinx  and  Prolapse  of  the  Uterus  and  Vagina. 


904  DISEASES   OF   WOMEN. 

her  she  had  had  nephrorrhaphy  performed  for  a  large  and  loose  kidney,  which 
was  also  explored,  as  it  was  thought  that  this  might  explain  the  bladder 
affection.     She  is  now  comparatively  well,  suffering  little  inconvenience. 

The  hypertemia  here  may  pass  on  into  ulceration  and  isolated 
ulcers,  giving  rise  to  heemorrhage.  Kelly  recommends  the  applica- 
tion directly  through  the  endoscope  of  a  three-per-cent.  solution  of 
nitrate  of  silver  on  a  piece  of  cotton.  Rest,  demulcent  drinks,  and 
the  internal  remedies  recommended  in  cystitis,  generally  afford  speedy 
relief. 

Gentle  washing  out  of  the  bladder  through  a  soft  catheter,  with 
warm,  weak,  alkaline  solution,  is  most  soothing. 

Matthew  Mann,  of  Buffalo,  has  rightly  insisted  on  the  reflex  ovarian  pains, 
the  occurrence  of  ureteritis  as  well  as  the  irritation  of  the  bladder,  that  may 
follow  upon  simple  acidity  and  condensation  of  the  urine.  At  the  same  time, 
it  is  right  to  observe  that  the  error  the  surgeon  is  most  likety  to  fall  into  is 
not  neglect  of  examination  of  the  urine  for  any  bladder  trouble,  but,  as 
has  been  already  pointed  out,  the  omission  of  seeking  for  an  explanation  in 
some  outside  source,  such  as  a  uterine  displacement,  a  tumour,  or  possibly 
haemorrhoids. 

Cystitis — Causation. — This  is  an  affection  which  the  gynsecologist 
has  constantly  to  deal  with,  whether  as  the  consequence  of  gonor- 
rhoea, exposure  to  cold,  pelvic  inflammatory  conditions,  or  following 
traumatic  causes,  either  operative  or  as  the  result  of  direct  violence. 

The  principal  causes  of  cystitis  are  : — 

Septic  organisms.  Gonorrhoea. 

Exposure  to  cold.  Calculus. 

Parturition.  Tumours. 

Habitual     neglect  of       the           Unclean  catheters  or  bougies. 

bladder.  Excessive  coitus. 

Uterine  displacements.  Parametritis. 

Unhealthy  urine.  Operations. 

Gout.  Injuries. 
Urethritis. 

Cystitis  has  been  divided  into  three  distinct  forms,  according  as 
the  entire  or  only  part  of  the  mucosa  is  attacked,  or  the  inflamma- 
tion is  scattered  in  patches — diffusa,  circumscripta,  dispersa. 

Septic  Organisms. — In  the  etiology  of  cystitis  the  part  played  by  organisms 
is  important,  some  special  bacteria  having  been  described  by  different 
authorities  as  present  in  a  large  proportion  of  cases — Bacterie  septique  de  la 
vessie  (Clado),  haderie  pyogene  (Halle),  as  well  as  the  staphylococci,  .the 
streptococcus,  and  diplococcus.     Melchoir  found  the  colon  bacillus  present  in 


AFFECTIONS  OF  THE  FEMALE   BLADDER.  005 


a  large  number  of  cases,  regarding  these  as  morphologically  the  same  as  the 
organisms  fonnd  by  Clado  and  Halle.  Kelly  gives  the  pathogenic  bacteria 
which  have  been  most  commonly  isolated  in  inflammation  of  the  bladder  as 
follows :  B.  coli  communis ;  streptococcus  pyogenes  ;  staphylococcus  pyogenes 
albus,  citreus,  and  aureus ;  bacillus  lactis  aerogenes;  liquifaciens;  the  gono- 
coccus;  typhoid  bacillus;  tubercle  bacillus,  and  several  forms  of  proteus. 

While  such  organisms  may  be  found  in  cystitis,  it  has  also  been  proved 
that  they  may  exist  in  the  bladder  without  causing  inflammation,  though 
some  of  them  are  necessary  attendants  upon  it,  requiring,  however,  some 
exciting  cause  to  start  the  inflammation.  Prom  this  we  can  readilj^  under- 
stand how  suppurative  conditions  of  the  pelvic  viscera,  discharges  from  the 
vulva,  suppurative  states  of  the  kidney,  and  direct  introduction  into  the 
bladder  by  uistrumentation,  may  set  up  cystitis. 

In  all  cases  in  which  there  is  doubt  as  to  its  cause,  a  careful  bacteriological 
examination  should  be  made,  especially  in  young  patients,  for  the  presence 
of  tubercle  bacilli. 


Pathogenic  Anaerobic  Organisms. 

Hartmann  and  Roger,*  iu  noticing  the  prevalence  of  anaerobic 
bacteria  in  the  pathogenesis  of  cystitis,  describe  a  special  organism 
which  is  invariably  present. 

'  In  saccharated  agar,  at  the  end  of  twenty-four  hours,  numerous 
bubbles  of  gas  had  formed,  spKtting  the  medium.  In  gelatine,  gas 
appeared  in  from  twenty -four  to  thirty-six  hoiu'S ;  then  ascending 
to  the  surface.  The  medium  showed  softening  about  the  third  day, 
and  liquefied  in  a  week.  When  this  latter  has  been  accomplished 
the  colonies  mount  to  the  surface  and  form  a  white  crust.  In 
bouillon  the  changes  are  much  the  same,  except  that  the  colonies 
form  a  precipitate.' 

'  Large  oval  bacilli,  attenuated  at  the  ends,  isolated  or  joined  into 
little  chains  of  from  two  to  five  individuals,  were  found  in  the 
anaerobic  cultures.  For  the  most  part,  they  are  but  slightly  stained, 
and  are  decolourized  by  Gram's  method.  The  authors  have  called 
this  organism  "  the  strepto-bacillus  f usif ormis."  Other  anaerobic 
bacteria  are  equally  pathogenic  to  this.' 

Symptoms. — The  symptoms  are :  increased  frequency  in  passing 
water,  irritabibty  at  the  neck  of  the  bladder,  with  pain  dui'ing,  and 
immediately  after,  the  act  of  micturition.  If  the  afiection  be 
chronic,  in  addition  to  the  frequency  of  passing  urine  and  the  pain 
present  in  the  acute  affection,  the  patient's  health  becomes  generally 
impaired,  and  there  is  pain  in  the  perineum  and  down  the  thighs 

*  Presse  Mifdicale,  Paris,  Xov.,  1902. 


906  DISEASES   OF    WOMEN. 

« 
or  in  the  supra-pubic  region.     Pain  is  also  experienced  on  a  vaginal 
examination  if  the  bladder  be  pressed  on  by  the  finger. 

The  Urine  is  generally  alkaline  and  phosphatic  ;  it  contains  a 
quantity  of  mucus,  decomposes  rapidly,  and  has  a  very  offensive 
odour.  Gradually  the  bladder  becomes  contracted,  and  a  smaller 
quantity  is  retained.  Later  on,  when  the  ureters  and  kidney  are 
inflamed,  ursemic  symptoms  may  be  present,  and  pus  as  well  as 
mucus  is  detected  in  the  urine. 

Changes  in  the  Bladder. — ^If  the  affection  be  not  cured,  con- 
gestion and  epithelial  desquamation  are  followed  by  thickening 
and  rugosity  of  the  mucous  membrane,  with  general  thickening  of 
the  muscular  and  connective  tissue.  The  orifices  of  the  ureters  are 
encroached  on,  the  tubes  become  dilated  and  are  generally  thickened. 
The  disease  travels  slowly  but  surely  backwards  ;  the  kidneys  finally 
yield  to  the  pressure  and  distension,  and  they  in  turn  become 
disorganized.  Ulceration  and  pus  accumulation  occur  both  in  the 
bladder  and  ureters. 

Course  and  Termination. — An  acute  attack  of  cystitis,  due  to  cold 
or  traumatic  cause,  if  properly  attended  to,  with  rest  and  suitable 
medication,  is  quickly  amenable  to  treatment.  Not  so  the  chronic 
form.  The  prognosis  is  unfavourable,  chronic  catarrhal  cystitis 
being  a  most  intractable  affection,  pursuing  the  course  above  indi- 
cated with  all  the  attendant  symptoms. 

Treatment. — In  acute  cystitis  the  treatment  will  consist  of :  Rest 
in  bed,  and  warmth ;  demulcent  drinks ;  milk  diet ;  linseed  tea, 
flavoured  with  clove.  Vittel,  Ems,  Contrexeville,  lithia,  potash  and 
other  alkaline  waters  may  be  taken  as  drinks. 

As  medicines,  the  decoction  of  pareira ;  the  infusions  of  buchu, 
uva  ursi,  and  scoparium  can  be  given  in  one-ounce  doses,  in  combi- 
nation with  the  tinctures  of  hyoscyamus,  buchu,  or  uva  ursi.  Liquor 
potassse,  lithiated  hydrangea,  hama;melis,  bicarbonate  of  potash  are 
useful  additions.  Large  draughts  of  decoction  of  tricitum  repens 
are  sometimes  soothing. 

A  warm  bath  will  occasionally  relieve  pain,  and  a  cocaine  or 
morphia  suppository  can  be  placed  in  the  rectum. 

An  admirable  mixture  I  find  is : — 

IV-     Liq-  potassEe,  5iss, 

Tinct,  uvse  ursi,  \  -.  .^g 
Tinct,  buchu,      r'  ^'  ' 
Tinct.  hyoscyami,  311, 
Liq.  hydrang',  lith,  ^^i. 


AFFECTIONS   OF   THE    FEMALE   li LADDER.  007 

Elixir  saccharin,  min.  xxx. 
Inf.  scoijarii  I       ?  --  -• 
Decoct,  parenu', ) 
.^i.  three  times  in  the  day.     M. 

Infusion  of  uva  ursi  or  buchu  may  be  substituted  for  the  broom.  The 
liquor  hydrangea  lithiatis  is  a  very  effective  preparation  in  irritation  of  the 
bladder — combined  %vith  hamamelis. 

The  bowels  are  regulated  by  such  saline  aperient  waters  as 
^sculap,  Apenta,  Rubinat,  or  Hunyadi  Janos,  and,  if  necessary, 
by  an  emollient  enema. 

The  oil  of  copaiba  or  cubebs  or  santal,  especially  in  cases  of  a 
specitic  nature,  may  be  given  suspended  in  the  mistura  amygdahe 
comp.  or  the  palatinoids  of  the  oils  of  copaiba  or  santal.  In  the 
latter  stages  the  benzoate  of  ammonia  in  fifteen  to  thirty  grain 
doses  is  a  useful  remedy.  Boric  acid  and  "  formolyptol "  can  be 
given  internally  if  the  urine  have  an  offensive  smell.  Matico  in 
infusion  and  tincture  I  have  found  useful  combined  with  hama- 
melis. Contrexeville  is  the  water  which  will  most  frequently  give 
relief  in  vesical  irritation.  The  bladder  should  in  all  obstinate 
cases  be  washed  out  at  least  twice  daily  with  some  weak  antiseptic 
lotion,  such  as  boric  acid,  carbolic  acid,  salicylic  acid  (a  few  grains 
to  the  ounce),  corrosive  sublimate  (1  in  100,000  gradually  increasing 
to  1  in  10,000),  formalin  (1  in  5000),  to  any  of  which  a  little 
hazeline  can  be  added.  This  may  be  done  with  a  double  catheter  and 
syphon-tube.  Hsemorrhoidal  conditions  require  attention.  Uterine 
displacements  should  be  rectified. 

Emmet's  Operation. — If  general  and  local  treatment  fail.  Emmet's  operation 
of  cystotomy,  to  give  the  bladder  rest  through  the  creation  of  a  vesico-vaginal 
fistula,  may  be  performed.  He  advocates  this  step  strongly,  going  so  far  as 
to  say  that  '  our  means  for  curing  cystitis  are  limited  to  a  single  procedure, 
that  of  vaginal  cystotomy,  and  all  other  means  yet  known  to  us  are  but 
adjuvants.' 

The  operation  consists  in  the  following  steps  : — 

1.  Placing  the  woman  in  the  posture  described  in  the  button-hole  operation 
on  the  urethra  (p.  892). 

2.  Introducing  a  curved  sound  or  a  fenestrated  staff  of  Harris  into  the 
bladder. 

3.  Seizing  the  projected  vaginal  tissue  with  a  tenaculum  in  the  middle 
line,  which  is  then  divided  with  a  pair  of  scissors  so  that  the  sound  may  be 
passed  into  the  vagina.  The  vesico-vaginal  septum  is  then  divided  in  the 
median  line. 

4.  Uniting  the  vaginal  and  vesical  edges  by  sutm'es,  as  before  described. 
Fallen  used  a  Paquelin's  cautery  to  open  the  bladder.     Emmet  disapproves 


908  DISEASES   OF   WOMEN. 

of  this  method,  inasmuch  as  there  is  risk  in  some  cases  of  injuring  the  bladder 
or  ureters.  Afterwards  the  bladder  is  freely  washed  out  through  the  opening 
with  warm  water.  In  due  time,  Avhen  the  cure  is  complete,  the  fistula  is 
closed. 

Kelly's  Treatment  of  Cliroiiic  Cystitis. — Kelly  recommends,  as  the  most 
efficient  way  of  treating  chronic  cystitis,  placing  the  patient  in  the  same 
position  as  that  adopted  for  cystoscopy,  and  to  expose  the  affected  spots, 
which  are  then  carefully  touched  with  a  solution  of  nitrate  of  silver  on  a 
cotton  pledget  of  from  3  to  5  per  cent. 

Treatment  by  Balloon. — Clark  uses  a  vesical  balloon.  It  is  made  of  rubber, 
which  can  be  rolled  round  and  grasped  in  a  urethral  forceps,  so  that  it  can 
be  carried  through  the  urethra  into  the  bladder.  The  parts  having  been 
thoroughly  disinfected,  the  bladder  is  emptied,  and  the  patient  placed  in  the 
knee-breast  position.  The  urethra  is  thoroughly  cocainized,  and  a  vesical 
speculum  is  next  introduced.  The  balloon  is  now  taken,  with  sterilized  hands, 
from  the  boric  acid  solution  in  which  it  has  been  placed  after  boiling. 
Sterilized  gelatine,  of  the  consistence  of  cold  olive  oil,  is  poured  on  the 
balloon  as  it  is  rolled  round  with  the  finger  and  thumb,  so  as  to  shape  it  into 
the  form  of  a  suppository.  In  this  shape  it  is  introduced  into  the  bladder  by 
the  forceps,  and  is  gradually  distended  by  means  of  a  syi'inge  pump.  There 
is  generally  pain  of  a  more  or  less  severe  character  both  during  and  for  some 
time  after  the  application,  which  may  be  alleviated  by  a  rectal  suppository  of 
opium.  The  air  is  prevented  from  escaping  from  the  balloon  by  a  clip  which 
is  placed  on  its  rubber  tube.  It  is  left  in  position  for  from  15  to  20  minutes. 
The  clip  is  then  removed,  the  balloon  aspirated  completely,  and  withdrawn 
from  the  bladder.  The  gelatine  may  contain  10  per  cent,  of  ichthyol.  The 
treatment  is  continued,  at  first  every  day,  and  afterwards  every  second  or 
third  day. 

Kelly's  Method  of  Opening  and  Draining  the  Bladder. 

Kelly,  under  the  head  of  a  new  and  better  method  of  opening 
and  draining  the  bladder  in  women,*  suggests,  in  old  cases  where 
there  are  areas  of  ulceration,  draining  the  bladder  for  some  weeks 
previously  to  operation,  and  keeping  the  patient  for  several  hours 
daily  in  a  tub  of  warm  water  at  a  temperature  of  100  to  102° 
Fahr.  The  steps  of  the  operation  ai^e :  The  bladder  having  been 
emptied,  the  patient  is  put  in  the  knee-breast  position,  and  a 
catheter  is  introduced  in  order  that  air  may  enter  the  bladder  and 
stretch  it.  The  posterior  vaginal  wall  is  now  lifted  by  an  assistant, 
so  as  to  stretch  the  anterior,  and  expose  it  with  the  portio  vagi- 
nalis. With  a  fistula-shaped  angular  knife  attached  to  a  handle 
with  a  double  bend,  the  vesico-vaginal  septum  is  pierced  at  a 
point  1\  cms.  in  front  of  the  cervix,  and  the  bladder  is  opened  by 

*  Amer.  Jour.  Obstet.,  and  Diseases  of  Women  and  Children,  vol.  xliv.,  No.  1, 
1901. 


AFFECTIONS   <>/■'    THE    FE.VALf:    ItLADDEI!. 


DO!  I 


carrying  the  knife  downwards  the  desired  length.     The  finger  is 
inserted  into  the  bladder,  and  the  internal  orifice  of  the  urethra 


Fig.  58r5. — Method  of  Opening  the  Bladder.    (Howard  Kellv.) 

having  been  located,  the  incision  is  carried  as  far  forwards  as 
desirable.  The  vesical  mucosa  is  now  drawn  through  the  incision, 
and  stitched  in  the  vaginal  mucosa  at  either  side. 

Gonorrhoeal  Cystitis. — The  management  of  a  case  of  gonorrhceal 
cystitis  must  be  conducted  on  the  same  lines  as  those  laid  down 
when  dealing  with  gonorrhceal  vaginitis.  While  treating  the  in- 
flammation on  general  principles,  and  in  the  manner  just  described, 
the  bladder  should  be  gently  irrigated  with  1  in  10,000  of  perch- 
loride  of  mercury,  alternated  with  weak  formalin,  boric  acid,  quinine, 
and  alkaline  solutions.  The  oils  of  santal,  cubebs,  and  copaiba,  are 
all  here  specially  indicated. 

Post-operative  and  Puerperal  Cystitis. — Neglect  in  proper  steri- 
lization, and  the  rough  use  of  catheters,  are  the  most  frequent 
sources  of  cystitis.  Post-operative  and  puerperal  cystitis  are  more 
often  due  to  this  than  any  other  cause.  After  the  operation  of 
curettage  a  mild  attack  of  cystitis  sometimes  occurs.  Women  are 
particularly  liable  to  iiTitation,  congestion,  and  inflammation  of  the 
bladder  after  the  operation  for  haemorrhoids,  therefore  particular 
attention  has  to  be  paid  to  the  bladder,  and  great  gentleness  used 
in  relieving  it  should  this  be  necessary  for  any  time  subsequent  to 
the  removal  of  the  piles.     In  many  cases  there  is  first  an  attack  of 


910  DISEASES   OF   WOMEN 

urethritis,  and  the  trouble  lasts  for  some  days,  and  is  limited  to  the 
urethra,  before  it  extends  to  the  bladder.  The  early  adoption  of 
soothing  treatment,  with  the  careful  withdrawal  of  the  urine,  will 
prevent  the  onset  of  the  graver  mischief. 

Cystitis  due  to  Uterine  Causes. — While  displacements,  tumours, 
and  peri-uterine  effusions  are  the  most  frequent  sources  of  vesical 
irritation  in  women,  they  do  not  often  cause  actual  inflammation 
unless  there  be  some  uterine  source  of  infection  in  the  shape  of 
discharge,  or  a  communication  of  a  fistulous  nature  between  the 
bladder  and  the  uterus,  or  the  adnexa. 

Bladder  Changes  in  Carcinoma  of  the  Uterus.^- — Cystoscopic 
examination  of  a  number  of  patients  by  Hirt  and  Sticher  showed 
that  in  carcinoma  of  the  cervix  and  portio  there  were  character- 
istic changes  in  the  trigone,  in  the  base  of  the  bladder  and  the 
internal  sphincter.  The  trigone  was  bulged  forward,  there  were 
irregularities  in  the  internal  sphincter,  with  vascular  changes  and 
abnormalities  in  the  openings  of  the  ureters,  and  papillary  and 
other  projections  in  the  mucous  membrane.  Folding  of  the  trigone, 
seen  when  the  bladder  is  distended,  shows  extension  of  the  malignant 
growth. 

Tubercular  Cystitis.f — The  bladder  may  be  infected  by  tubercle, 
either  from  the  kidney  above  or  the  urethra  below.  Of  great 
importance  to  the  gynaecologist  is  the  knowledge  of  the  fact  that 
tuberculous  disease  may  find  its  way  through  the  involvement  of 
ureter  or  bladder  from  a  suppurating  pelvic  abscess,  or  pyo-salpinx. 
Some  of  these  cases  are  difficult  to  diagnose,  and  demand  careful 
examination  of  the  kidney,  ureter,  and  bladder,  as  well  as  the 
pelvic  cavity  and  the  lungs.  The  difficulty  of  diagnosis  is  in  the 
earlier  stages  of  the  disease,  before  ulceration  has  occurred,  and 
the  urine  becomes  purulent.  There  may  be  a  tuberculous  family 
history.  Diagnosis  is  completed  by  the  discovery  of  the  character- 
istic organism,  which  may  be  found  either  in  the  urine,  or  by 
removal  through  the  cystoscope  of  a  small  portion  of  the  affected 
mucous  membrane,  by  the  curette,  or  lever  forceps. 

The  treatment  of  tubercular  cystitis,  and  tuberculous  ulcer  of  the 
bladder,  must  be  conducted  on  the  same  lines  on  which  we  proceed 
to  treat  the  disease  when  occurring  elsewhere.  Apart  from  the 
general    treatment    of   the   case,    hygienic    and    therapeutic,    local 

*  JDeuUch.  Med.  Wocli.,  Oct.  29,  1903. 

t  For  the  relation  of  tubercular  affections  of  the  kidney  and  ureter  to  the 
bladder,  see  the  chapters  dealing  with  these  organs. 


AFFECTIONS   OF   THE   FEMALE    l: LAUDER.  911 


remedies  have  to  be  applied.  Once  the  local  condition  has  been 
determined,  the  cystoscope  will  have  to  be  employed  for  the  purpose 
of  topical  application.  By  means  of  it  an  ulcor  can  bo  curetted,  or 
an  application  of  nitrate  of  silver  made.  The  operation  of  curettage 
of  the  bladder  may  be  performed  for  obstinate,  chronic,  or  tuber- 
cular cystitis.  The  bladder  having  been  rendered  as  aseptic  as 
possible  by  repeated  antiseptic  washings,  the  finger  is  introduced 
into  the  vagina  and  the  curette  into  the  bladder.  The  finger  thus 
acts  as  a  point  of  counter-pressure,  regulating  the  force  with  which 
the  curette  is  used.  Successively  various  portions  of  the  bladder  are 
carefully  gone  over  with  the  curette,  or,  if  the  disease  be  circum- 
scribed, this  area  alone  is  dealt  with. 

Supra-pubic  Cystotomy. — The  operation  of  cystotomy  as  a  dernier 
ressort  consists  in  the  supra -pubic  incision  of  the  bladder,  the  suturin<y 
of  the  edges  of  the  bladder  wall  temporarily  to  the  skin,  the  exposure 
of  the  diseased  surface,  and  the  excision  of  the  affected  mucosa.  The 
closure  of  the  bladder  wound  is  effected  by  catgut  sutures,  and  is 
followed  by  that  of  the  abdominal  incision  in  the  usuul  manner.  JSTo 
drainage-tube  is  used. 

Tuberculosis  of  the  Urinary  Organs. — Guy  Hunner,  writing  in 
the  Johns  HopMns  Bulletin  (Jan.,  1904),  from  the  records  of  twenty- 
eight  cases  arrives  at  these  conclusions  :  Urinary  tuberculosis  in 
women  is  a  disease  of  young  adults,  generally  occurring  in  the  kidney 
primarily,  and  confined  to  one  side.  Bladder  symptoms  are  those 
usually  first  complained  of.  Appendicitis  and  colic  from  gall  stones 
may  be  mistaken  for  the  renal  disease,  and  must  be  differentiated. 
It  is  not  incompatible  with  a  long  life,  and  in  some  cases  spontaneous 
healing  may  take  place.  In  nearly  50  per  cent,  of  the  cases  heredity 
appeared  to  play  a  part  in  the  causation. 

Stone  in  the  Bladder. — The  symptoms  of  the  presence  of  stone 
are — 

Frequency  in  passing  water. 

Pain,  principally  felt  after  passing  water. 

Presence  of  blood  in  the  urine. 

Presence  of  phosphates  and  mucus. 

The  stone  is  felt  by  the  sound  or  finger,  and  is  seen  by  the 
cystoscope. 

Foreign  bodies  often  form  the  nuclei  of  calculi.  Howard  Kelly 
records  this  interesting  case  : 

A  hairpia  was   introduced   by  the   patient,  a  young  unmarried  woman, 


912 


DISEASES   OF    WOMEN. 


who  married  a  short  time  afterward.  She  passed  through  a  confinement 
without  any  injury  to  the  bladder,  although  the  calculus  had  already  formed 
about  the  pin,  and  was  felt  by  the  doctor  in  attendance,  who  pushed  it  up 
into  the  abdomen  while  the  head  was  descending  through  the  pelvis.  No 
explanation  could  be  obtained  from  the  patient  as  to  how  the  hairpin  got  into 
the  bladder,  but  the  mother,  who  saw  it  after  removal,  declared  that  she  must 
have  swallowed  it. 

Tenison  Collins  removed  a  penholder,  having  accidentally  discovered  it  in 
the  bladder  when  operating  for  stenosis  of  the  uterine  canal  for  dysmenorrhoea. 
The  patient  had  introduced  it  two  and  a  half  years  previously. 


Fig.  584. — Hairpin  Calculus. 
(Howard  Kelly.) 


Fig.  585.— Metal  Penholder  (three 

INCHES   LONG.      (TeNISON  CoLLINS.) 

Removed  from  the  bladder  of  a  patient, 
aged  25,  by  vaginal  cystotomy. 


Lithotrity.— To  Otis,  of  New  York,  we  owe  the  teaching  which 
has  established  the  possibility  of  introducing  large  instruments  into 
the  bladder.  To  Bigelow  we  are  indebted  for  the  modern  operation 
of  crushing  stone  in  the  bladder,  and  removing  the  fragments  at  one 
sitting  by  aspiration  (litholapaxy).  The  operation  is  performed 
thus  :  The  presence  and  size  of  the'  stone  having  been  determined, 


AFFECTIONS  OF  THE  FEMALE  BLADDEB.  913 

the  patient  is  placed  under  ether  in  the  lithotomy  position.  If  no 
urine  be  in  the  bladder,  a  few  ounces  of  warm  sterilized  water  are 
injected.  The  lithotrite  is  introduced,  and  the  stone  is  crushed. 
(The  student  is  familiar  with  the  more  minute  descrij^tion  of  this 
step,  and  the  details  of  the  operation  of  lithotrity  in  the  case  of  stone 
in  the  male  bladder).  The  large  evacuating  catheter  is  now  intro- 
duced, and  the  bladder  is  emptied.  The  modern  improved  aspirator 
is  then  attached  to  the  catheter,  and  about  three  ounces  of  warm 
water  is  injected  intt)  the  bladder.  With  the  outflow  the  fragments 
are  received  into  the  glass  bulb  attached  to  the  aspirating  bag. 
Larger  fragments  which  remain  are  crushed  and  removed  in  the 
same  manner.  Other  details  of  the  operation,  as,  for  instance,  the 
method  of  seizing  and  crushing  the  stone,  the  removal  of  all  the 
debris,  and  the  freeing  of  large  particles,  are  the  same  as  in  lithotritv 
on  the  male.  The  woman  may  be  given  a  warm  hip-bath  and  an 
opiate  some  hours  after  the  operation,  if  there  be  pain.  Alkaline 
drinks  are  indicated,  and  any  symptoms  of  cystitis  attended  to. 

P.  J.  Frej'er,  one  of  the  most  expert  of  lithotritists,  remarks  that  in  a  series 
of  litholapaxy  operations,  all  turning  out  successful,  there  were  thirteen  cases 
of  stone  in  females.  One  woman,  from  whom  he  removed  a  stone  over  an 
ounce  in  weight,  was  seven  months  pregnant,  and  made  an  excellent  recovery. 
The  only  special  difficulty  met  with  in  this  operation  in  the  female  is  in 
retaining  water  in  the  bladder  during  its  performance.  Owing  to  the  short- 
ness and  width  of  the  urethra,  the  water  rushes  out  beside  the  instruments. 
This  may  be  obviated  by  an  assistant  placing  the  fore  and  middle  fingers  of 
one  hand  in  the  vagina  and  pressing  the  posterior  lip  of  the  urethra  against 
the  lithotrite  or  cannula. 

Vaginal  Cystotomy, 

If  either  from  the  size  of  the  stone,  the  state  of  the  bladder,  or  the 
condition  of  the  health  of  the  woman,  the  operator  should  wish  to 
perform  lithotomy,  an  opening  is  made  of  sufficient  size  in  the  vaginal 
septum,  and  the  stone  is  extracted.  The  bladder  is  subsequently 
washed  out  by  the  urethra,  and  the  vaginal  wound  treated  as  a 
vesico-vaginal  fistula. 

Removal  of  Small  Calculi  by  tlie  Fingers. — Halliday  Groom  recommends 
that  the  fingers  be  used  (Fig.  586)  for  pushing  small  calculi  from  the  bladder 
into  the  urethra,  and  through  it  from  the  meatus.  If  the  urethra  he  dilated, 
this  proceeding  is  facilitated.  This  plan  is  limited  to  stones  no  larger  than 
the  finger-tip. 

Treatment  of  Incontinence  by  Forcible  Dilatation  of  the  Bladder  (H.  Marion 
Sims). — H.  Marion  Sims,  for  incontinence  of  urine  in  young  girls,  pi'actises 

^    3    N 


914 


DISEASES   OF    WOMEN. 


Fig.  586. — Ceoom's  Pkoceduke. 


forcible  dilatation  of  the  bladder.    In  all  the  patients  he  has  found  the  bladder 
so  contracted  that  it  held  but  a  few  ounces,  or  less ;  in  one  case,  that  of  a  girl 

of  thirteen  years  of  age,  it  only  held 
three-quarters  of  an  ounce.  The 
plan  adopted  is  the  daily  injection 
of  comfortably  warm  water  into  the 
bladder  to  the  point  of  distension, 
increasing  the  quantity  by  half  an 
ounce  to  an  ounce  each  day  until 
the  retaining  power  of  the  bladder 
is  improved;  then  it  is  practised 
every  second,  day,  and,  finally,  once 
in  the  week.  He  has  succeeded  in 
getting  these  patients  to  retain 
twelve  and  eighteen  ounces  com- 
fortabl3^  In  some  cases  he  com- 
bined the  use  of  a  mild  Faradic 
cuiTent  applied  to  the  neck  of  the 
bladder  with  the  dilatation. 

Alexander's  Recto-Vesical  Opera- 
tion for  Incontinence  from  Fistula. — 
William  Alexander*  practises  'a 
method  of  treating  incontinence  of 
urine  in  the  female  in  cases  hitherto 
considered  to  be  beyond  the  resources  of  surgery.'  The  principle  of  this 
method  consists  in  conveying  the  urine  into  the  rectum,  and  converting  the 
anus  into  the  permanent  channel  for  its  escape.  The  anal  sphincters  are 
thoroughly  dilated ;  the  base  of  the  bladder  is  pushed  into  the  rectum  with 
the  finger,  on  Avhich  the  rectal  wall  is  divided,  so  as  to  form  a  communication 
between  the  bladder  and  rectum;  into  this  one  end  of  a  vulcanite  stud  is 
inserted,  so  that  the  flat  head  of  the  stud  is  in  the  bladder  and  the  screw- 
end  protrudes  into  the  rectum ;  on  this  the  other  end  of  the  stud  is  screwed, 
and  a  permanent  opening  is  thus  secured  between  the  bladder  and  rectum. 
The  next  step  in  the  operation  consists  of  complete  closure  of  the  vulvar 
orifice  by  separating  the  labia  minora  from  the  labia  majora  all  round,  and 
turning  the  epithelial  surface  of  the  former  towards  the  bladder,  suturing 
the  two,  and  finally,  completely  closing  the  latter.  This  operation  has  given 
rise  to  a  good  deal  of  criticism  ;  but  it  must  be  remembered  that  the  con- 
dition for  which  it  was  proposed  is  a  desperate  one.  In  otherwise  inoperable 
cases,  and  if  by  it  we  can  better  succeed  in  closing  completely  the  vulvar 
orifice,  and  the  diversion  of  the  urinary  stream  does  not  make  the  woman's 
condition  worse  through  rectal  irritation,  this  ingenious  device  of  Alexander's 
is  worth  a  trial. 

Tumours  and  Growths. — Carciaonia,  papilloma,  sarcoma,  and 
fibroma  are  found  in  the  bladder.  Polypi  occur  rarely,  save  in  the 
case  of  children. 

*  Brit.  Gyn.  Jour.,  Aug..  1898. 


AFFECTIONS   OF   THE   FEMALE   ULADDER.  915 


Benign  and  Malignant  Tumours. — The  tumours  found  in  the 
bladder  have  been  already  enumerated.  Probably  villous  growths 
are  those  which  we  most  frequently  meet  with,  but  there  is  a 
special  difficulty  in  the  differentiation  between  benign  and  malignant 
tumours  of  the  bladder,  both  pathologically  and  clinically.  Also, 
the  early  diagnosis  of  tumour  of  the  bladder  is  a  matter,  in  many 
cases,  of  extreme  difficulty,  inasmuch  as  the  earlier  symptom  of 
frequency  of  micturition,  or  difficulty  in  passing  the  urine,  amount- 
ing to  retention  and  pain,  is  present  in  ordinary  cystitis. 

Kiister  classifies  *  tumours  of  the  bladder  according  as  they  arise 
from  the  connective,  the  muscular,  or  the  glandular,  tissues.  As 
regards  the  situation  in  which  neoplasms  are  more  frequently 
found,  the  neighbourhood  of  the  base  of  the  bladder  is  most  often 
their  seat.  Tumours,  again,  are  pediculated,  and  these  are  either 
single  or  multiple.  Pediculated  tumours  are  of  the  myxomatous 
type,  are  generally  found  near  the  neck  of  the  bladder,  and  occur 
during  early  life. 

Diagnosis. — When  the  presence  of  a  tumour  of  the  bladder  is 
suspected,  the  first  step  to  take  is  to  have  an  exhaustive  chemical 
and  microscopical  examination  made  of  the  urine.  Any  shreds  of 
tissue  which  pass  are  submitted  to  the  microscope.  Bi-manual 
palpation  of  the  bladder  through  the  vagina  is  made,  and  the 
size,  direction,  and  relations  of  the  growth  are  determined.  Such 
steps,  however,  are  only  preliminary  to  cystoscopy,  carried  out  in 
one  of  the  ways  that  has  been  described. 

Symptomatology. — The  symptoms  of  tumour  of  the  bladder  are 
often  obscure.  The  most  characteristic  symptom  of  malignant 
disease  is  haemorrhage.  Hgematxu'ia  may  not,  however,  occur  for  a 
considerable  time  after  the  earlier  symptoms  of  frequency  in  passing 
water,  and  slight  supra-pubic  pain,  have  been  complained  of.  The 
haemorrhage  often  is  periodical.  An  interval  of  time  elapses,  and 
then  the  bleeding  continues  for  a  short  time  and  again  ceases.  In 
other  instances  it  is  persistent  and  alarming.  In  any  case  of  htema- 
turia,  the  first  point  to  decide  is  the  source  of  the  blood,  and  next, 
having  localized  this  in  the  bladder,  to  determine  by  cystoscopy  if 
the  cause  be  a  tumour,  and,  if  so,  the  size,  and  if  possible  the  nature, 
of  the  growth. 

It  is  impossible  to  over-estimate  the  importance  of  haematuria  as 
a  diagnostic  sign,  and  as  an  indication  for  examination,  not  of  the 
bladder  only,  but  also  of  the  ureters  and  kidneys.  This  necessitates 
*  Volm.,  >>ammlung  Klin.  Tort. 


916  DISEASES   OF    WOMEN. 

vaginal,  as  well  as  vesical  and  rectal,  exploration,  with  careful 
palpation  of  the  kidneys.  To  show  the  importance  of  this  step,  I 
may  cite  the  following  case  : — 

Mixed  Cell  Sarcoma  of  the  Bladder. — The  patient  had  suffered  for  a  con- 
siderable time  from  symptoms  of  cystitis,  and  for  the  last  three  months  from 
severe  haematuria.  She  had  been  treated  on  the  Continent  for  cystitis. 
After  her  return  home,  the  growth  was  first  discovered  per  vaginam.  It  was 
located  in  the  immediate  neighbourhood  of  the  neck  of  the  bladder,  and 
occupied  the  base  and  posterior  wall  of  the  viscus.  Particles  bi'ought  away 
after  exploring  and  washing  out  the  bladder  did  not,  on  microscopical  ex- 
amination, throw  light  on  the  exact  nature  of  the  gi'owth.    It  was  determined 


%    / 
/ 


\ 


Fig.  587. — Mixed  Cell  Saecoma  of  the  Bladder. 
(Author — Section  by  Taegett.) 

to  dilate  the  urethra  and  remove  it.  This  was  done  satisfactorily,  and  no 
bleeding  occurred  subsequent  to  the  operation.  Unfortunatelj^,  septic 
symptoms  set  in,  followed  by  suppression  of  urine,  death  occurring  on  the 
sixth  day  after  operation. 

'  This  tumour  may  fairly  be  described  as  a  mixed-cell  sarcoma,  the  round 
and  oval  shapes  predominating,  and  the  short  spindles  being  in  less  abun- 
dance. It  is  very  vascular,  and  the  vessels  are  mostly  of  the  thin-walled 
type  characteristic  of  sarcomata.  The  surface  of  the  tumour  is  covered 
with  granular  matter,  due  to  ulceration  and  sloughing  of  the  sarcomatous 
tissue.  In  consequence,  there  are  evidences  of  diffused  inflammation'  in 
the  growth  immediately  subjacent  to  the  necrotic  layer,  and  these  inflam- 
matory changes  complicate   the   structure   of  the   tumour   throughout   the 


AFFECTIONS   OF    THE   FEMALE   liLAIUiEl:.  917 

microscopic  section.  Several  giant-cells  are  to  be  seen  in  every  section,  but 
they  are  not  numerous  enough  to  call  the  growth  "  myeloid."  Such  giant- 
cells  are  not  uncommon  in  rapidly  growing  sarcomata.  To  the  naked  eye 
the  specimen  had  a  nodular  or  bossy  outline,  but  did  cot  appear  to  be 
covered  with  mucous  membrane,  as  is  usual  when  sarcomata  bulge  into  the 
cavity  of  the  bladder.'  ^'     (Fig.  oST.) 

Dermoid  of  the  Bladder. 

Bogareski  f  has  published  the  case  of  a  woman  of  33  wlio  had  been  treated 
for  catarrh  of  the  bladder  for  several  years.  A  diagnosis  of  calculus  was 
made,  and  the  urethra  was  dilated.  A  pyriform  tumour  with  a  thin  pedicle 
was  removed  by  the  ecraseur ;  it  was  covered  with  skin  and  contained  hair, 
bone,  and  teeth. 

Also,  Muench  %  has  collected  the  particulars  of  twenty-four  cases  in  which 
the  bladder  has  been  encroached  on  and  perforated  by  dermoid  cyst ;  he 
himself  recording  a  case  in  which  this  occurred  from  a  dermoid  of  the  ovary. 

Supra-pubic  Cystotomy. 

In  supra-pubic  cystotomy  the  bladder  is  reached  by  a  clean 
incision  in  the  usual  manner.  All  bleeding  is  arrested,  the  pre- 
vesical fat  is  carefully  divided,  and  the  peritoneum  is  pushed 
upwards  -with  the  finger.  The  bladder  is  then  transfixed  trans- 
versely with  a  hook,  and  is  next  opened  in  the  median  line,  the 
incision  being  carried  downwards  towards  the  symphysis. 

The  margins  of  the  vesical  wound  are  now  caught  at  either  side 
with  catch  forceps,  and  held  apart.  Should  there  be  difficulty  in 
retaining  the  edges  of  the  bladder,  and  preventing  it  from  descend- 
ing out  of  reach,  a  few  sutures  may  temporarily  be  passed  through 
it  so  as  to  fix  it  to  the  abdominal  wall.  The  tumour  is  now  exposed, 
and  removed  by  dissection,  ecraseur,  or  curette  forceps.  In  some 
cases  portions  of  the  bladder  are  resected  with  the  growth,  and 
after  extirpation  the  wound  is  closed  by  catgut  sutures,  and  the 
bladder  is  constantly  drained.  Should  the  ureter  be  cut  or  wounded 
in  extii'pation,  a  transplantation  operation  has  to  be  performed. 
The  closure  of  the  bladder  mucosa,  or  its  entire  w^all,  demands 
considerable  care  and  nicety.  The  abdominal  wall  is  closed  in  the 
usual  manner. 

In  these  operations  an  electric  photophore  or  forehead  mirror  is 
most  useful,  but  this  may  be  dispensed  with  if  the  electric  lamp, 
with  reflector,  be  availed  of. 

*  Brit.  Gyn.  Jour.,  Feb.,  1897.  f  Pract.  ■  Vratch,  IdO'I,  No.  5. 

t  Zeits.f.  EeW:.,  b.l.  xxiii..  lieft  i. 


918 


DmEASES   OF    WOMEN. 


Colpo-cystotomy. 

In  cases  where  we  are  in  doubt  of  the  feasibility  of  removal  by 
the  urethra,  or  when  we  may  have  to  resect  a  portion  of  the  bladder 
wall  with  the  tumour,  colpo-cystotomy  is  to  be  preferred.  The 
growth  is  exposed  through  the  vaginal  incision,  the  edges  of  which 
are  held  apart,  and  the  tumour  extirpated.  Kelly  recommends 
transfixion  of  the  latter  at  some  distance  from  the  field  of  operation, 
so  as  to  hold  it  in  place  dui'ing  the  operation,  thus  avoiding  the  risk 
of  heemorrhage  and  delay  from  the  open  wound  pulling  back  into 
the  bladder. 

Pediculated  Papilloma. 

In  a  case  of  pediculated  papilloma  of  the  bladder,  Kelly  let  air 
into  the  latter,  the  patient  being  in  the  knee-face  position,  and 
then  incised  through  the  septum,  drawing  its  edges  and  those  of 
the    bladder    wall    into   the    vagina.       Through    the    opening    the 


Figs.  588,  589. — Thompson's  Foeceps  for  Removal  of  the  Tumours  from 
THE  Bladder. 


pedicle  was  ligated,  and  the  tumour  removed.  The  vaginal  wound 
was  closed  with  silver  wire  down  to  the  bladder  mucosa,  and  a 
small  catheter  was  left  for  drainage.  The  wound  closed  sponta- 
neously. Subsequently  the  pedicle  ligature  was  removed  through 
the  urethral  speculum. 


AFFECTTONFi   OF   THE   FEMALE   BLADDER.  91ii 


Treatment. — The  only  treatment  for  vesical  tumours  is  operation. 
In  old  a^e,  Kelly  says,  and  in  childhood  under  five  years,  the  growth 
is  almost  certainly  malignant  and  inoperable.  The  routes  by 
means  of  which  a  tumour  may  be  removed  are  by  the  urethra  or 
vagina,  and  supra-pubically.  Cystectomy  was  first  successfully 
carried  out  by  Pawlik  "'  (Lapthorn  8mith).  As  in  the  case  just 
quoted,  if  it  be  feasible  the  urethra  may  be  selected  as  the  most 
favourable  route  for  extirpation.  After  full  dilatation  of  the 
urethra,  the  growth  may  be  removed  by  the  galvano-cautery  snare, 
or  knife.  This  applies  more  particularly  to  pediculated  tumours,  or 
polypi. 

Thompson's  bladder  forceps  (Figs.  588,  589,)  with  fenestrated 
blades,  or  the  curved  one  with  serrated  edges,  may  be  used  in 
some  cases  to  remove  the  growth  piecemeal. 

*   Central,  fiir  Gyn.  Beitrage,  1890,  p.  U?,. 


CHAPTER   XLVI. 

AFFECTIONS    OF   THE   URETERS. 

In  the  chapters  dealing  with  the  anatomical  facts  bearing  upon 
gynsecological  practice,  the  surgical  anatomy  of  the  ureters  has  been 
discussed,  as  also  the  best  method  of  examining  them,  both  by  in- 
spection and  palpation.  I  here  describe  fully  the  methods  of  cathe- 
terization of  the  tubes  as  first  practised  by  Howard  Kelly,  also  the 
direct  method  by  the  electric  cystoscope  of  Nitze, 

The  affections  of  the  ureters  that  the  gynsecologist  has  to  deal 
with  are — 


Double  ureter. 
Ectopic  ureteral  orifice. 
Ureteritis. 
Hydro-ureteritis. 
Pyo-ureteritis. 


Calculus. 

Stricture. 

Fistula. 

Prolapse. 

Wounds. 


Ectopic  Ureteral  Orifice. 

The  Condition  of  Double  Ureter  does  not,  save  in  wounds  of  the 
ureter,  affect  the  surgeon.  The  second,  through  the  constant 
dribbling  of  urine  from  the  vagina  or  some  portion  of  the  urethra, 
must  attract  attention,  though  the  difiiculty  of  rectifying  the  defect 
is  great. 

The  first  point  to  decide  is  whether  the  discharge  of  urine  is  from 
an  abnormal  ureteral  orifice,  or  from  some  vaginal  or  urethral 
fistula. 

This,  independent  of  the  history  of  the  case,  may  be  determined 
by  careful  searching  of  the  distended  vagina,  mopping  the  vaginal 
wall  carefully  with  absorbent  cotton-wool,  so  as  to  detect  any 
small  orifice ;  by  injecting  the  bladder  with  a  coloured  solution, 
either  of  aniline  or  sterilized  milk,  and  noticing  that  this  does  not 
affect  the  urine  as  it  escapes.* 

*  See  pp.  924,  925,  930,  931,  for  Kelly's  method  of  Catheterization  and 
Exploration  of  the  Ureters,  also  the  appliances  required. 


AFFECTIONS   OF  THE    URETERS. 


921 


normal  5pLit  U.       Doable  U. 


U 


arrest  of 
catheter 


E.O. 


no  arrest  of 
catheter 


E.O 


Fig.  590. — Diagnosis  of  Split  and  Double  Ureter. 

Differentiation  of  an  Ectopic  Ureteral  Orifice. — Kelly  proposes  to  solve  the 
questions  (1)  whether  the  opemng  is  ureteral,  and  with  which  kidney  it  is 
connected;  (2)  whether  it  is  a 
single  or  double  ureter,  and,  if  the 
latter,  if  there  be  a  normal  open- 
ing into  the  bladder;  (3)  if  a 
double  ureter,  if  it  be  so  as  far  as 
the  kidney,  or  if  there  be  a  fusion 
at  some  point  above  the  bladder  ; 
and  lastly,  if  the  ureter  be  double, 
do  the  tubes  open  into  separate 
pelves  in  the  kidnej^,  or  into  one 
pelvis  common  to  both.  If  a  long 
renal  bougie  can  be  passed  up 
the  ureter  for  30  centimetres,  it 
may  be  palpated  through  the 
vagina  and  rectum,  thus  deter- 
mining the  site  of  the  abnormal 
ureter. 

By  direct  inspection  of  the 
bladder  the  ureteral  orifices  may 
be  seen  in  normal  position,  and 
if  they  be  so  placed  at  both  sides 
it  demonsti'ates  the  fact  that  the 
abnormal  ureteral  orifice  is  the 
result  of  either  a  double  or  split 
ureter.  The  mode  of  diagnosis 
may   be    readily   understood   by 


Fig.  .591. — Kiunev  wrru  D.iuiiLE  I'klvis 
AND  Double  Ureters.    (H.  Kelly.) 

1,  Purulent  collection ;  2,  calculus  in  upper 
pelvis;  3,  lower  pelvis;  4,  marks  limit 
of  akiograph ;  5,  junction  of  ureter. 


drawing  a  rough  diagram  of  a  kidney  with  a  double  ureter,  one  entering  the 


922  DISEASES   OF   WOMEN. 

bladder,  and  one  continued  on  for  some  distance  to  enter  the  vaginal  canal : 
by  the  side  of  this,  another  diagram  of  a  kidney  with  a  split  ureter,  the 
bifurcation  taking  place  at  a  short  distance  below  the  kidney,  and  the  ureters 
opening  below  as  in  the  other  case. 

The  question  as  to  whether  the  ureter  is  completely  double,  or  split,  and, 
if  the  latter,  at  what  distance  from  the  kidney,  Kelly  settles  thus :  He  passes 
through  the  abnormal  orifice  a  catheter  sufiSciently  large  to  fill  the  ureter 
and  as  far  as  the  pelvis  of  the  kidney.  He  next  passes  through  the  normal 
opening  of  the  bladder  a  second  catheter.  If  it  be  a  split  ureter,  this  last  will 
be  arrested  at  the  junction  of  the  two  tubes  where  the  split  occurs,  and  by 
comparing  the  distance  relatively  that  both  catheters  have  been  passed,  we 
may  arrive  at  the  position  of  the  bifurcation.  The  procedure  may  be  reversed, 
so  as  to  verify  the  diagnosis  (Fig.  590). 

The  treatment  resolves  itself  into  transplantation  of  the  ureter  into  the 
bladder,  or,  in  the  case  of  a  double  ureter  with  a  single  renal  pelvis, 
ligating  the  abnormal  ureter  at  some  point  where  it  can  be  conveniently  laid 
bare.* 

Ureteritis. — The  causes  of  ureteritis  are,  according  to  Mann,  in- 
juries during  parturition,  vesical  disease,  gonorrhoea,  pyo-nephritis, 
abnormal  urine,  tuberculosis,  and  such  pelvic  affections  as  peri- 
uterine phlegmon,  peritonitis,  and  tumours.  Septic  conditions  of 
the  bladder  may  infect  the  ureters.  The  pathological  consequences 
of  the  ureteritis  are  seen  in  epithelial  desquamation,  ulceration, 
and  purulent  secretion.  Such  conditions  bring  about  considerable 
thickening  of  the  tube. 

Edgar  Gareeanf  classifies  ureteritis  under  three  heads:  (1)  simple;  (2) 
luith  obstruction ;  (3)  tubercular. 

Simple  may  be  either  acute  or  chronic.  The  acute  form  is  frequently 
associated  with  parturition,  especially  in  primiparae.  The  symptoms  are 
pelvic  pain,  bladder  irritation,  and  sensitiveness  of  the  ureter  felt  through 
the  vagina.     There  are,  as  a  rule,  pyelitis  and  cystitis  present. 

The  chronic  form  is  frequently  the  result  of  vesical  or  renal  inBammation, 
and  the  gonococcus  one  of  the  more  common  causes.  Frequency  of  micturi- 
tion during  the  day  and  night,  pelvic  pain,  and  insomnia  are  the  principal 
symptoms.  The  cystoscope  shows  a  swollen  ureteral  orifice  of  the  intiamed 
ureter.  The  urine  contains  an  excess  of  desquamated  epithelium,  and  there 
is  tenderness  of  the  duct  when  it  is  pressed  upon  in  the  vagina. 

Differential  diagnosis  must  be  made  between  ureteritis,  salpingitis,  ovaritis, 
ureteral  stricture,  and  appendicitis.  It  is  of  considerable  importance  to  make 
an  early  diagnosis,  as  in  a  measure  prognosis  depends  upon  this.  In  the 
treatment,  everything  pressiug  on  the  ureter,  such  as  diseased  adnexa,  must 
be  removed,  and  the  colon  kept  empty.  The  special  remedies  he  recommends 
are  urotropine  and  santal-wood  oil,  with  bicarbonate  of  soda ;  and  as  a  vesical 

*  Kelly, '  Operative  Gynaecology,'  vol.  i.  p.  420. 
t  Amer.  Jour.  Med.  Sci.,  Feb.,  1903. 


AFFECTION!^  OF  THE    URETERS.  023 

injection,  protargol  (5  per  cent.)  or  ichythyol  (50  per  cent.).  Two  drachms  of 
either  are  injected  and  allowed  to  remain  for  half  an  hour.  Topically, 
Gtvreean  applies  boracic  acid  or  nitrate  of  silver  through  the  cystoscope.  As 
a  dernier  ressort,  a  vesico-vaginal  fistula  should  be  made. 

Obstructive  ureteritis  he  divides  into  partial  and  complete.  The  former 
may  be  due  to  fibrous  stricture  or  calculus.  Constant  desire  to  urinate  is  a 
characteristic  symptom  of  stricture.  Diagnosis  will  depend  upon  the  passage 
of  the  ureteral  bougie,  and  the  treatment  is  dilatation ;  the  passage  of  ureteral 
bougies,  or  Kelly's  catheters  twice  in  the  week.  Otherwise,  an  extra-peritoneal 
operation  has  to  be  performed,  the  sti'icture  divided  on  a  ureteral  catheter, 
and  the  remainder  of  the  duct  examined  for  other  strictures,  Uretero- 
cystotomy  should  be  performed  if  the  stricture  be  close  to  the  bladder ;  if 
high  up,  nephro-ureterectomy  may  have  to  be  performed. 

In  calculus  obstruction  there  is  a  history  of  renal  colic,  and  possibly  hajma- 
turia,  with  the  symptoms  of  cystitis,  and  a  calculus  mnj  be  felt  per  vaginum. 
The  X-rays  should  be  availed  of.  Leonard,  out  of  206  cases,  obtained  positive 
results  with  these  in  65.  K  the  calculus  be  not  passed,  the  extra-peritoneal 
method  should  be  adopted  for  its  removal. 

In  complete  obstruction  due  to  fibrous  stricture,  if  it  be  acute  the  severity  of 
the  symptoms  of  pyelitis  and  pyelonephritis  clear  up  the  difficulties  in  diagnosis. 
In  the  chronic  cases  we  have  infiammation  of  the  ureter  below  the  stricture, 
which  may  extend  to  the  bladder,  with  consequent  cystitis.  The  ureter  is 
dilated,  and  there  is  thickening  of  its  fibrous  coat.  All  the  usual  symptoms 
of  pyelonephritis  are  present,  while  pressure  over  the  renal  region  excites 
resistance  of  the  abdominal  muscles,  and  there  may  be  enlargement  of  the 
kidney.  The  cystoscope  reveals  evidence  of  cystitis,  and  the  passage  of  a 
ureteral  catheter  is  followed  by  the  flow  of  accumulated  urine  and  pus. 

The  treatment  Kelly  divides  under  four  heads :  nephrectomy,  dilatation 
"with  bougies,  cystotomy,  and  the  creation  of  an  artificial  fistula  above  the 
strictured  portion. 

In  the  diagnosis  of  complete  obstruction  from  calculus,  there  has  been 
some  pre-existing  proof  of  concretion  in  the  kidney,  the  urine  does  not  flow 
on  the  obstructed  side,  and  colic,  with  attacks  of  hsematuria,  have  been  present. 
Exploration  of  the  kidney  and  the  passage  of  a  sound  into  the  ureter  will 
determine  the  presence  of  the  stone,  or  this  may  also  be  arrived  at  hy  ureteral 
catheterization  from  below. 

With  regard  to  the  prevalence  of  ureteral  tuberculosis,  out  of  3424  autopsies 
at  the  Boston  City  Hospital  and  the  Massachusetts  General  Hospital,  this 
afi'ection  of  the  ureter  was  present  in  64  cases,  40  of  these  being  of  the  miliary 
type  and  24  of  the  caseous ;  and  of  194  cases  of  nephrectomy  noted  by 
Gareean,  the  ureter  was  affected  with  tuberculosis  27  times.  Any  special 
symptoms  due  to  the  ureter  are  masked  by  the  renal  and  vesical  ones,  the 
principal  symptom  being  colic,  while  the  ureter  may  be  detected  through  the 
vagina  as  a  thickened,  solid,  and  sensitive  cord. 

Symptomatology. — Frequency  of  micturition,  and  boring  pain  in 
the  course  of  the  ureters.  Mann  notices  especially  the  mental  de- 
pression attending  on  these  cases. 


924  DISEASES  OF   WOMEN. 

Diagnosis. — The  diagnosis  of  ureteritis  by  digital  examination  is 
by  no  means  easy,  and  we  are  indebted  to  Howard  Kelly  for  more 
explicit  instructions  for  examination  of  the  ureter.  The  bladder 
and  rectum  having  been  emptied,  the  finger  palpates  the  antero- 
lateral wall  of  the  vagina,  and  if  the  ureter  be  enlarged  or  dis- 
tended and  inflamed,  the  sensitive  tube,  cord-like  in  the  case  of 
simple  ureteritis,  is  found  extending  from  the  vaginal  vault  to 
beneath  the  base  of  the  broad  ligament,  and  is  doubtless  often 
mistaken  for  an  inflamed  and  sensitive,  or  enlarged  ovary  in  this 
position.  Again,  by  laterally  seeking  for  the  sciatic  notch  through 
the  rectum,  it  may  be  found  in  proximity  to  the  internal  iliac  artery. 
Only  in  rare  cases,  when  the  abdominal  wall  is  very  thin  and 
relaxed,  is  it  possible  to  feel  the  thickened  ureter  by  abdominal 
palpation. 

The  majority  of  patients  can  be  catheterized  without  ansBsthesia. 
The  catheterization  may  be  carried  out  either  in  the  dorsal  or  the 
knee-face  position.  If  in  the  former,  the  buttocks  should  be  brought 
well  over  the  edge  of  the  table,  the  pelvis  being  raised  either  on 
bran  bags  or  an  inclined  plane.  If  in  the  latter,  the  patient  is 
placed  as  shown  in  Fig.  577,  p.  897.  As  this  method  is  the  one 
most  generally  followed,  I  will  give  Kelly's  instructions  for  carrying 
it  out.  The  first  steps  are  those  already  described  in  examination 
of  the  bladder  (p.  897),  up  to  the  localization  of  the  ureteral  orifices 
through  the  urethral  speculum.  The  ureteral  end  of  the  catheter 
is  not  touched,  but  is  guided  up  to  the  speculum,  the  lumen  of 
which  has  been  carefully  sterilized.  If  a  flexible  ureteral  catheter 
be  used,  the  orifice  of  the  ureter  is  localized,  and  kept  in  view  by 
means  of  the  speculum.  The  silk  catheter,  already  steriKzed,  and 
lubricated  in  a  boro-glyceride  solution,  is  now  taken  hold  of  by  its 
end  with  the  sterilized  fingers,  or  sterilized  rubber  finger-stalls. 
Under  all  circumstances,  careful  sterilization  is  carried  out.  The 
catheter  is  now  guided  to  the  ureteral  orifice.  During  this  manipu- 
lation the  other  end  of  the  catheter  is  supported  on  the  shoulder 
of  the  examiner.  When  it  is  introduced,  the  speculum  is  with- 
drawn, and  care  is  taken  that  the  patient  does  not  by  movements 
in  position  pull  the  catheter  from  out  of  the  ureter.  The  ureteral 
catheters  are  30  centimetres  in  length,  and  the  renal  50,  that  is, 
12  and  20  inches  respectively.  They  are  made  of  woven  silk, 
coated  and  rubbed  down  to  a  highly  polished  surface. 

The  catheters  are  kept  in  sterilized  tubes,  closed  at  both  ends 
with  sterilized  cotton.     The  metal  ureteral  catheter  is  12  inches 


AFFECTIONS  OF   THE    URETERS. 


925 


loag  ('i'J  centimetres)  and  2\  millimetres  in  diameter.  Its  shape 
and  character  is  shown  in  the  drawing.  It  is  made  in  two  sizes, 
the  more  convenient  for  passing  measures  a  millimetre  and  a  half 
in  diameter.  There  are  three  oval  eyes  at  the  extremity  of  the 
catheter.  The  bougies  used  by  Kelly  are  made  either  of  metal  or 
hard  rubber.  Some  are  of  the  same  shape  as  the  catheters.  They 
are  two  millimetres  in  diameter,  and  some  twenty  inches  in  length. 
Some  of  the  hard  rubber  ones  are  so  grooved  at  the  tip  that  they 
hold  a  little  dental  wax,  so  that  when  the  bougie  comes  in  contact 
with  the  calculus,  the  scratch  on  the  surface  of  the  wax  can  be 
seen  with  a  lens.  A  silk  renal  catheter,  tipped  with 
wax,  effects  the  same  object.  The  dilating  catheters  ^T 
are  metal  tubes,  nickel  plated,  and  have  a  curve  at 
either  end,  terminating  in  a  tapering  conical  blunt 
point.  To  the  outer  end  of  the  catheter  a  rubber 
tube  can  be  attached. 

'  By   elevating  the  handle  of  the   speculum,   the 


Fig.  .592. — Irrigation  of  the  Ureter  ix  a  Case  of  Pyo-eretekiti.'?. 
(Howard  Kelly.) 

By  changing  the  position  of  the  body  from  the  genupectoral  to  the  horizontal, 
the  antiseptic  (boric)  solution  flows  in  and  out. 

field  of  vision  sweeps  over  the  base  of  the  bladder  until  in  some 
cases  the  region  of  the  inter-ureteric  ligament  comes  into  view, 
often  marked  by  a  slightly  elevated  transverse  fold  or  a  distinct 
difference  in  colour.  By  turning  the  speculum  thirty  degrees  to 
one  side  or  the  other  and  looking  sharply,  a  ureteral  orifice  is  dis- 
covered. "While  inspecting  the  ureter  I  have  frequently  observed 
little  jets  of  urine  ejected  at  short  intervals,  like  a  miniature  foun- 
tain ;  in  pathological  cases  I  have  seen  pus  and  blood  flowing  from 
one  ureter  while  tlie  other  discharged  normal  urine.' 


926  DISEASES   OF   WOMEN. 

'  The  ureteral  orifices  and  their  surroundings  are  not  constant  in 
appearance.  Sometimes  the  orifice  appears  as  a  dimple  or  a  little 
pit ;  or,  in  inflammatory  cases,  as  a  round  hole  in  a  cushioned 
eminence  ;  at  other  times  as  a  round  hole  with  the  point  directed 
outward ;  again,  it  may  be  scarcely  visible  even  to  a  trained  eye, 
appearing  as  a  fine  crack  in  the  mucosa,  and  occasionally  is  so 
obscure  as  to  be  recognized  only  by  the  jet  of  urine  as  it  escapes,  or 
by  a  slight  difference  in  the  colour  of  the  mucous  membrane  at  that 
point.  In  rare  cases  it  has  the  form  of  a  truncated  cone  with 
gently  sloping  sides  ;  this  appearance  is  most  apt  to  be  developed  in 
the  knee-breast  position.' 

'  The  bladder  mucosa  is  usually  of  a  slightly  deeper  rose  colour 
around  the  ureter,  and  in  the  presence  of  an  inflammatory  process  it 
even  appears  deeply  injected.' 

'  In  the  direct  inspection  the  ureteral  orifice  always  appears  to 
lie  nearer  the  urethra  than  one  would  anticipate.  This  is  a  result 
of  the  illusion  produced  by  the  foreshortening  of  the  base  of  the 
bladder.' 

X-Eay  Examination. — Every  case  of  suspected  ureteral  calculus  should  be 
examined  by  the  Rontgen  ray,  and  a  radiograph  obtained.  At  the  same 
time,  we  must  be  prepared  for  an  occasional  misleading  result  of  this  test.* 
For  instance,  in  a  case  of  Noble's,  a  ureteral  calculus  was  pronounced  to  be 
present.  On  operation  there  was  no  calculus ;  as  a  consequence,  the  original 
trouble  was  aggravated  by  a  perforation  of  the  ureter  caused  by  exploration 
of  the  duct  during  the  operation.  This  fistula  was,  however,  completely 
closed.  The  same  caution  applies  to  the  kidney,  and  unsatisfactory  shadows 
supposed  to  be  due  to  calculus  have  not  infrequently  led  to  useless  exploration 
of  the  organ. 

In  another  case  of  Noble's  a  most  satisfactory  result  followed  diagnosis  by 
the  X  ray.  By  an  extraperitoneal  operation,  the  ureter  was  incised  over 
the  stone,  and  the  latter  extracted.  With  chromic  and  cumol  gut  the  ureter 
was  closed,  and  the  result  was  perfect. 

Illumination  of  tlie  Abdominal  and  Pelvic  Viscera.f  Von  Ott  has  intro- 
duced a  method  of  examination  of  the  abdominal  cavity  in  diagnostic 
examination  and  for  operative  purposes.  The  patient  is  placed  in  the 
extreme  Trendelenburg  position,  as  in  Pryor's  operation  (Fig.  385),  at  an  angle 
of  forty-five  degrees.  The  legs  are  in  the  lithotomy  position.  Thus  the  intes- 
tines are  removed  from  the  pelvis.  The  pouch  of  Douglas  is  previously 
opened  from  the  vagina,  thus  facilitating  the  descent  of  the  pelvic  viscera 
through  the  admission  of  air  into  the  abdominal  cavity.  Anterior  and 
posterior  specula,  of  different  shapes  and  curves,  are  introduced,  the  former 
containing  an  electric  lamp,  which  enables  the  observer  to  see  not  only  the 

*  Amer.  Med.,  Sept.  27,  1903. 

t  Monats.  f.  Geb.  u.  Gyh.,  bd.  xviii.,  lieft  .5. 


AFFECTIONS   OF   THE    URETERS.  927 

pelvic,  but  alsu  the  abdomiiuil  viscera.  The  vaginal  opening  is  closed  by  some 
sterilized  wool  before  the  patient  is  placed  in  the  required  i)osition.  The 
examination  can  be  conducted  under  anaesthesia.  In  150  cases  examined, 
no  bad  result  had  followed.  V.  Ott  enumerates  different  conditions  under 
which  such  illumination  is  of  service,  both  in  diagnosis  and  for  operations. 

Further  Details  of  Catheterization. 

Should  the  dorsal  position  be  the  one  selected,  the  following  are  Howard 
Kelly's  directions  for  his  procedure  :  *  The  bladder  having  been  cathcterized, 
careful  palpation  of  the  ureters  is  made  so  as  to  locate  them  anteriorly  through 
the  vaginal  wall,  whether  they  be  well  forward  under  the  bladder,  or  are 
found  abnormally  far  back  in  the  pelvis. 

'  The  bladder  is  next  distended  with  from  5  to  7  ozs.  of  the  analine  solution. 
The  posterior  vaginal  wall  is  retracted  with  a  speculum,  exposing  the  anterior 
wall  up  to  the  cervix,  while  the  bladder  is  being  injected. 

'  The  object  of  this  distension  of  the  bladder  is  twofold :  in  the  first  place 
it  does  away  with  all  the  rugosities  of  a  contracted  bladder,  which  hinder 
catheterization,  if  they  do  not  render  it  impossible.  The  only  rugosities  left 
are  the  prominences  on  either  side,  through  which  the  mouths  of  the  ureters 
open  into  the  bladder  by  a  little  slit,  running  obliquely  backward  in  a  line 
with  the  course  of  the  ureters. 

'  The  second  reason  is  well  exhibited  pictoriall^^  by  Professor  Pawlik,  who 
was  the  first  to  demonstrate  that  the  curved  folds  which  cross  the  anterior 
vaginal  wall  out  to  the  lateral  walls  and  around  toward  the  cervix  are  valuable 
landmarks  in  finding  the  ureters,  which  lie  parallel  to  and  just  above  them. 
These  are  appropriately  called  for  this  reason  the  "  ureteral  folds."  They  are 
brought  out  distinctly  by  moderate  distension  of  the  bladder. 

'  An  assistant  should  determine  that  the  catheter  is  clear  by  placing  the 
end  in  water,  and  blowing  through  it  without  touching  it  with  his  lips.  The 
metal  plug,  attached  by  a  short  chain  to  the  catheter,  is  coated  with  a  little 
vaseline,  and  inserted  in  the  outer  end,  thus  keeping  the  aniline  solution  from 
filling  the  lumen  of  the  catheter  when  it  enters  the  bladder.' 

Passag-e  of  Catheters. 

'  In  order  to  carry  the  ureteral  catheter  or  sound  over  the  hrini  of  the  pelvis, 
it  is  not  necessary  to  use  a  flexible  instrument.  This  can  be  effected  by  first 
filling  the  bladder  w'ith  sufficient  fluid  to  distend  its  folds  and  introduce  the 
catheter  into  the  ureter,  and  then  drawing  off  all  the  contents  of  the  bladder ; 
a  finger  introduced  into  the  rectum  high  up  gently  lifts  the  catheter,  and 
assists  it  over  the  brim  and  on  up  into  the  abdomen.  This  mana?uvre  is 
rendered  possible  by  the  loose  cellular  tissue  in  which  the  pelvic  organs  lie 
allowing  a  wide  displacement  of  bladder,  ureter,  and  broad  ligament  without 
injury.  The  contracted  bladder  can  be  lifted  up,  while  it  is  impossible  to 
displace  the  full  bladder  in  this  way. 

'  It  is  now  evident  that  if  clear  or  straw-coloured  fluid  escape  through  the 
catheter  it  must  be  urine,  as  the  dee[)  aniline  coloixr  of  tiie  fluid  in  the  bladder 


928  DISEASES  OF   WOMEN. 

renders  deception  from  that  source  impossible.  When  the  catheter  is  intro- 
duced as  far  as  the  bladder^  touch  and  sight  assist  in  its  further  introduction 
into  the  ureter. 

'  By  turning  its  point  forward  and  elevating  the  handle,  a  slight  prominence 
is  produced  on  the  anterior  vaginal  wall.  Throughout  the  manipulations  of 
the  catheter  this  is  the  constant  guide  to  the  vesical  orifice  of  the  ureter. 
The  fii'st  step  after  the  introduction  of  the  catheter  into  the  bladder  is  to  try- 
to  locate  the  ureteral  eminence  by  the  sense  of  touch  communicated  from  the 
tip  of  the  catheter. 

'  To  this  end  the  movements  of  the  point  on  the  anterior  vaginal  wall  are 
closely  watched  as  it  plays  over  the  base  of  the  bladder.  It  is  made  to  glide 
gently  in  a  fore  and  aft  direction  from  the  neck  of  the  bladder  to  the  cervix, 
in  the  median  line,  a  little  to  one  side,  a  little  further  out,  and  so  on  until  it 
reaches  the  ureteral  eminence,  when  it  is  distinctly  felt  to  trip,  jogging  the 
thumb  and  finger  in  which  the  catheter  is  held. 

'  The  same  movement  is  repeated  until  this  point  is  exactly  located.  The 
attempt  is  now  made  to  introduce  the  catheter  into  the  ureter  by  carrying 
the  handle  to  the  opposite  side,  thus  directing  the  point  toward  the  posterior 
lateral  wall  of  the  pelvis,  when  the  catheter  is  withdrawn  slightly,  and  with 
its  point  still  down,  but  turned  a  little  more  toward  the  side,  is  swept  down- 
ward, outward,  and  backward  in  the  direction  of  the  ureteral  prominence. 
With  each  of  these  sweeping  motions  the  catheter  is  rotated  until  the  point  is 
directed  fully  outward  or  slightly  upward. 

'This  movement,  employed  in  engaging  the  catheter  in  the  ureter,  may 
very  appropriately  be  c&]le([  fisliing  for  the  ureter. 

'  As  soon  as  the  catheter  enters  the  ureter  its  course  is  fixed,  and  the  tactile 
sense  at  once  recognizes  that  it  no  longer  lies  free  in  the  bladder  as  before. 
If  the  catheter  be  released  for  a  moment  the  handle  does  not  drop,  but 
remains  in  a  fixed  position  and  forms  an  angle,  of  about  30°,  with  a  line  pro- 
jecting from  the  urethra.  The  catheter  should  be  carried  into  the  ureter  until 
its  point  reaches  the  wall  of  the  pelvis,  when  the  plug  is  removed  from  the 
end.  Another  may  now  be  introduced  into  the  opposite  ureter,  and  both  be 
thus  catheterized  at  the  same  sitting. 

'On  account  of  the  partial  occlusion  of  the  urethra  by  the  first  catheter, 
the  second  is  slightly  more  difficult  to  introduce. 

'  If  it  be  desirable  to  carry  the  catheter  higher,  even  over  the  brim  of  the 
pelvis  and  up  to  the  pelvis  of  the  kidney,  the  bladder  can  be  emptied  by 
introducing  a  small  glass  catheter  under  the  two  ureteral  catheters.  The 
contracted  bladder  now  forms  a  movable  organ,  which  can  be  displaced 
upward  without  harm  in  manipulatmg  the  ureteral  catheters. 

'  With  an  index-finger  mtroduced  into  the  rectum,  the  catheter  is  lifted  up 
and  guided  while  it  is  pushed  on  up  over  the  pelvic  brim  and  up  to  the  pelvis 
of  the  kidney. 

'  As  soon  as  the  plug  of  each  catheter  is  withdrawn,  an  assistant  notes  the 
time,  so  as  to  be  able  to  tell  afterwards  just  how-  long  the  urine  has  been 
flowing  from  each  kidney.  The  minim  graduates  are  held  below  the  catheters 
to  catch  the  urine.  An  average  of  1500  c.c,  or  about  three  pints,  is  the 
normal  daily  excretion  of  urine.     If  from  both  catheters  one  cubic  centunetre 


AFFECTIONS   OF   THE    URETEHS.  ;.29 

a  minute,  or  half  a  cubic  centimetre  from  one  catheter,  is  passed,  the  number 
of  minutes  in  a  day  multiplied  by  this  amount  gives  1440  c.c,  which  is 
practically  the  normal  excretion.  Kelly  frequently  found  just  this  proportion 
upon  estimating  the  day's  urine  by  the  amount  collected  ia  a  few  minutes  by 
the  catheters. 

'Oftener  the  amount  falls  much  below  normal.  In  disease  there  is  fre- 
quently a  marked  difference  in  the  amount  of  urine  collected  from  the  two 
sides.  One  side  may  flow  freely  and  the  other  discharge  no  urine,  although 
this  may  be  due  to  stricture,  which  I  have  demonstrated  by  pushing  the 
catheter  up  beyond  the  stricture  and  over  the  brim  of  the  pelvis,  when  im- 
mediately several  ounces  escaped.  One  side  may  be  alkaline  and  the  other 
acid ;  one  may  be  bloody  or  pure  blood  and  the  other  clear  urine  ;  one  may 
be  pus  and  the  other  urine. 

'  The  mine  evidently  flows  from  the  kidney  in  little  wavelets.  It  does 
not  appear  at  the  end  of  the  catheter  for  from  one  to  eight  or  ten  minutes, 
and  then  it  only  escapes  by  drops  at  intervals  of  a  few  seconds  to  a  minute 
or  more. 

'  Fifteen  minutes  is  an  average  time  for  the  duration  of  the  catheterization. 
The  urine  of  each  side  is  then  marked  and  set  aside  for  examination.  The 
catheters  are  plugged  and  withdrawn,  and  the  urine  in  each  of  them  is  added 
to  that  in  the  graduate  from  the  same  side.  A  little  patience  and  tact,  as 
I  have  said,  are  all  that  is  needed  to  succeed  in  this  little  manoeuvre,  which 
adds  so  much  to  the  possibilities  of  gynaecology,  as  it  brings  into  this  s{  ec!al 
branch  of  surgery  renal  diseases  in  the  female. 

'A  valuable  aid  for  the  beginner  searching  for  the  ureteral  orifice  is  as 
follows  :  A  point  is  marked  on  the  cystoscope,  5^  centimetres  from  the  vesical 
end,  and  from  the  point  two  diverging  lines  are  drawn  towards  the  handle, 
with  an  angle  of  60°  between  them.  The  fpeculum  is  introduced  up  to  the 
point  of  the  V,  and  turned  to  right  or  left  until  one  side  of  the  V  is  in  line 
with  the  axis  of  the  body ;  then  by  elevating  the  endoscope  until  it  touches 
the  floor  of  the  bladder  the  ureteral  orifice  will  usually  be  found  within  the 
area  covered  by  the  orifice  of  the  speculum.  The  ureteral  orifice  can  often 
be  found  by  an  adept  at  once,  and  almost  instinctively,  by  a  single  movement 
of  the  speculum  after  its  introduction  into  the  bladder. 

'  In  order  to  ascertain  whether  it  be  the  ureter  which  lies  within  the  field, 
Kelly  uses  as  a  searcher  (Fig.  597\  a  long  delicate  sound  with  a  handle  bent 
at  an  angle  of  120°,  which  is  introduced  through  the  speculum  into  the  sus- 
pected ureteral  orifice,  and  the  lateral  walls  of  it  are  slightly  raised,  appearing 
as  distinct  folds  with  a  dark  pit  between  them.  The  searcher  may  be  with- 
drawn and  a  ureteral  catheter  at  once  introduced,  if  it  is  desirable  to  collect 
the  urine  direct  from  the  kidney.  The  ureteral  catheters  which  I  use  for 
direct  catheterization  are  quite  different  from  those  heretofore  employed. 
They  are  straighter,  and  either  have  no  handle  or  only  a  small  one  which  will 
readily  pass  through  the  Xo.  10  speculum.' 

Kelly  recommends  the  following  method  for  obtaining  a  small 
quantity  of  urine  from  the  ureter  without  catheterization.  The 
speculum   is  pushed  close   under   the   ovitice   of  the  ureter   in   tl.e 

3   o 


980 


DISEASES   OF    WOMEN. 


Howard  Kelly's  Appliances  for  Ureteral  Catheterization. 


Fig.  593. — Uketeral  Catheter  with  Keduced  Handle. 


Fig.  594.— Uketeral  Catheters  without  Handles. 


Fig.  596. — Urine  Collector. 


Fig.  598. — Hard  Ureteral  Catheters. 


.IFF ACTIONS   OF   THE    URETERS. 


Its  I 


bladder,  the  drop  of  urine  is  caught  by  the  speculum,  and  runs 
down  its  side  to  the  outer  lip,  where  it  is  taken  on  a  slide  for 
microscopical  examination.     He  has  also  devised  a  urine  collector. 


Fig.  599. — HAnc-niBBEK  Bougies  ixtkoduced  into  both  UiiETEiis  previous 
To  Hysterectomy  for  Carcixcuia. 

The  instrument  is  shown  in  the  drawing.*     It  is  used  with  the 
speculum,  and  may  be  carried  through  it  with  the  patient  lyiiig  on 


Fig.  000. — Stricture  of  Eight  Ureter  demonstrated  by  Catheterizatiox. 

Catheter  passed  up  above  striclure,  followed  by  a  rapid,  continuous  flow  of  urine, 
while  urine  escaj  ed  by  drops  in  much  less  quantity  from  opposite  side. 
Difference  in  quantity  of  urine  obtained  in  the  same  time  frum  both  ureters 
shown  in  conical  glasess. 

her  back.  As  this  metliod  of  exploration  is  also  applicable  to  the 
passage  of  a  bougie  into  the  ureter  before  an  operation  for  hystei-ec- 
tomy,  I  give  his  description  in  his  own  words  : — '  The  patient  lies 

*  Fis.  o9G. 


932  DISEASES   OF    WOMEN. 

on  her  back  on  a  flat  table,  with  thighs  well  drawn  up  on  the  body, 
and  the  bladder  is  emptied.  The  No.  9  or  10  cystoscope  is  now 
introduced,  and  its  outer  end  strongly  elevated,  the  inner  being 
turned  toward  the  right  or  left  side  of  the  base  of  the  bladder.' 
The  speculum  is  now  withdrawn  as  far  as  the  urethral  orifice  to 
locate  its  position,  and  then  pushed  in  again  and  turned  to  one  side 
with  the  idea  of  bringing  the  ureteral  orifice  at  once  within  the 
lumen  of  the  speculum.  If  there  be  difficulty  in  seeing  the  ureteral 
orifice,  the  speculum  is  pressed  against  the  bladder  wall,  and  then, 
after  drying  out  the  few  drops  of  urine  in  it,  the  orifice  is  found  by 
gliding  the  instrument  over  the  vesical  mucosa,  and  the  ureteral 
searcher  is  used  to  discover  it.  When  found,  a  catheter  is  pushed 
into  the  ureter,  and  thus  the  surgeon  can  easily  feel  the  tube  during 
operation. 

Tubercular  Ureteritis. — If  the  -ureteritis  be  of  a  tubercular  cha- 
racter, Ave  are  more  likely  to  have  both  pus  and  blood  in  the  urine, 
as  the  bladder  mucosa  is  generally  affected  as  well  as  that  of  the 
ureter.  In  all  cases  where  tubercular  infection  is  suspected,  a 
bacteriological  examination,  in  addition  to  a  cystoscopic,  will  be 
necessary.  From  the  experiments  of  Grunbaum  it  may  be  con- 
cluded that,  in  the  majority  of  cases,  the  characteristic  bacillus  is 
not  likely  to  be  confused  with  the  smegma  bacillus  of  the  external 
Sfenitals,  if  there  be  careful  catheterization  of  the  bladder,  and  the 
first  portion  drawn  off"  be  rejected  when  securing  the  specimen  to 
be  examined ;  otherwise  the  organism  is  apt  to  be  confounded  with 
that  of  tubercle.  Under  any  circumstances,  however,  the  discovery 
of  the  tubercle  bacillus  in  the  urine  is  very  uncertain,  and  it  may 
escape  detection,  especially  if  we  have  not  a  sufficient  sediment  for 
examination.  It  must  be  remembered  that  in  the  majority  of  cases 
the  kidney  is  primarily  involved,  and  there  are  all  the  evidences  of 
nephritis  and  pyo-nephritis  presenj;  in  addition  to  those  which  are 
due  to  the  affected  ureter. 

Obstructed  Ureter — Causes. — The  ureter  may  be  obstructed  by 
tumours,  both  ovai^ian  and  uterine,  peri-uterine  effiisions,  malignant 
disease  of  the  uterus  and  adnexa,  broad  ligament  adhesions  and 
contractions,  iliac  aneurisms,  tumours  or  calculus  in  the  bladder, 
and  thickening  of  the  bladder  wall  itself.  It  may  also  be  obstructed 
by  a  coagulum  of  blood  or  growth,  specific  or  cancerous,  which  has 
its  origin  in  the  urethral  walls,  in  consequence  of  gonorrhoeal  or 
other  inflammation  spreading  to  the  tubes.  Whether  one  or  two 
ureters  are  likely  to  be  involved  in  the  obstruction,  will  depend  in 


A/'FECT/OXS   OF    THE    URETEJtS.  !»:)3 


great  measure  on  the  cause ;  as,  for  instance,  in  malignant  disease 
of  the  cervix  uteri,  both  are  likely  to  bo  affected,  whereas  in  such 
cases  as  smaller  pelvic  tumours,  peri-uterine  phlegmon,  and  tuber- 
culosis, one  only  may  be  affected.  Outside  these  causes  there  are 
those  operative  and  post-operative  ones  due  to  ligature  or  wounds. 
The  immediate  consequence  of  such  obstruction  is  either  hydro- 
ureter  or  hydro-uephrosis. 

Symptoms. — It  is  most  difficult  to  locate  ureteral  pain,  but  if,  in 
the  presence  of  any  of  these  causes  of  obstruction,  there  should  be 
pain  in  the  course  of  the  duet,  attended  by  frequent  desire  to  pass 
water,  the  obstructive  condition  may  be  suspected.  In  a  person  of 
gouty  habit,  in  whom  there  has  been  pre-existing  evidence  of  gouty 
kidney,  verified  by  urinary  analysis,  there  is  the  likelihood  of  a 
calculus  blocking  the  lumen  of  the  ureter,  especially  if  the  pain 
should  come  on  suddenly  and  partake  of  the  nature  of  renal  colic. 
Such  pain,  if  it  arise  in  association  with  pelvic  suppuration,  and 
the  presence  of  pus  in  the  urine  which  varies  in  quantity,  will 
also  lead  to  the  suspicion  that  the  ureter  is  involved  in  the  pelvic 
inflammation.  The  possibility  of  the  obstruction  being  due  to 
stricture  is  not  to  be  forgotten.  The  probability  that  this  is  the 
cause  is  increased  if  the  presence  of  tubercle  or  gonorrhoea  has  been 
ascertained. 

Stricture. — The  diagnosis  of  stricture  can  only  be  made  by 
passing  the  ureteral  catheter  in  the  manner  taught  by  Kelly, 
who  has  reported  cases  in  which,  by  gradual  dilatation  with  hollow 
bougies,  a  stricture  has  been  overcome  without  operation.  In  this 
case,  however,  the  treatment  had  to  be  prolonged  for  some  months.* 
Such  cases  of  stricture  are  rarely  met  with  in  women,  save  as  the 
result  of  some  pelvic  operation. 

Hydro-ureter. — Hydro-ureter,  as  the  term  implies,  is  a  dilated 
condition  of  the  tube  due  to  obstruction,  arising  under  one  of  the 
circumstances  which  I  have  indicated.  Either  from  pressure  from 
without,  or  blockage  within  the  tube,  it  is  frequently  associated 
with  distension  of  the  renal  pelvis  or  hydro-nephrosis.  External 
pressure  is  most  likely  to  affect  the  ureter  as  it  crosses  the  pelvic 
brim  (Figs.  25,  26),  and  consequently  there  is  a  general  dilatation  of 
the  ureter  as  far  as  the  kidney.  The  same  state  will  follow  from 
the  impaction  of  a  calculus  near  its  vesical  end.  A  large  tumour, 
either  in  the  pelvis  or  in  the  bladder,  may  cause  double  hydro-ureter 
with  hydro-nephrosis  of  both  kidneys. 

*  Kelly,  '  Operative  Gynecology,'  vol.  i.  p.  4:i!8,  <t  ceq. 


934  DISEASES  OF   WOMEN. 


Pyo-ureter.* — Pyo-ureter  is  the  consequence  of  some  infection 
reaching  a  ureter,  which  has  probably  been  previously  obstructed. 
Gonorrhoea,  tuberculosis,  pyo-nephrosis  with  renal  calculus,  or 
cystitis,  may  result  in  hypertrophy  and  interstitial  changes  in  the 
walls  of  the  bladder. 

Calculus.—  A  calculus  is  more  frequently  aiTested  in  the  upper 
portion  of  the  tube  near  the  pelvis  of  the  kidney.  The  symptoms 
of  stone  in  the  ureter  are  often  very  obscure.  If  it  be  lodged  in 
the  ureter,  there  may  be  slight  elevation  of  temperature,  rapidity 
of  pulse,  intense  pain,  extending  from  the  loin  to  the  inguinal 
region,  and  at  the  same  time  a  frequent  desire  to  pass  urine, 
in  which  blood  is  present.  The  method  of  palpation  of  the  ureter 
has  already  been  referred  to,  in  treating  of  the  anatomy  of  the 
tube.  By  this  means,  if  the  stone  be  low  down  in  the  neighbour- 
hood of  the  bladder,  it  may  be  felt  through  the  rectum  or  the  vagina. 
A  preliminary  examination  having  been  made  to  confirm  the  sus- 
picion that  attacks  of  ureteral  colic  arouse,  the  patient  is  placed  in 
the  position  generally  availed  of  in  examination  for  renal  calculus, 
and  the  lumbar  region  is  carefully  and  bimanually  palpated.  Dis- 
tension from  hydro-nephrosis  may  be  detected.  It  may  then  be 
possible,  in  the  dorsal  decubitus,  by  pressure  in  the  course  of  the 
ureter,  to  detect  a  specially  painful  and  circumscribed  spot. 

A  stone  may  protrude  through  the  ureteral  orifice,  or  it  may  so 
invest  the  ureter  as  to  form  a  sort  of  sack,  in  the  centre  of  which 
lies  the  calculus.     Possibly  this  might  be  mistaken  for  a  tumour. 

Calculus  in  the  ureter,  if  felt  by  the  finger,  may  be  removed 
through  the  rectum  or  the  vagina,  and,  if  partly  protruding,  possibly 
by  the  bladder.  If  in  other  situations,  the  operation  of  retro- 
peritoneal ureterotomy  has  to  be  performed,  by  which  step  the 
ureter  is  reached  between  the  kidney  and  the  true  pelvis.  After 
the  removal  of  the  stone  by  a  longitudinal  incision,  the  ureter  is 
sutured. 

In  any  case  where  the  symptoms  of  calculus  arise,  examination 
hj  palpation  should  be  made  in  the  manner  already  described. 

Diagnosis  of  Ureteral  Calculus  by  Wax-tipped  Bougie. — Kelly 
has  reported  different  cases  of  diagnosis  of  ureteral  calculus  by 
means  of  the  wax-tipped  bougie.  The  coating  of  a  catheter,  say 
2  mm.  in  diameter,  is  made  with  a  wax  and  olive-oil  mixture,  two 
parts  of  the  former  to  one  of  the  latter.  The  steps  of  the  operation 
are — cocainization  of  the  ureter  by  direct  injection,  or  eucaine  may 
*  See  pp.  407,-423,424. 


AFFECTIONS   OF    THE    URETKllS.  !t35 

be  substituted ;  examination  of  the  ureteral  orifices  through  the 
cystoscope  ;  the  introduction  of  a  ureteral  sound  for  examination 
of  the  ureter  and  the  detection  of  stricture ;  dilatation  of  the  ureter 
by  a  ureteral  dilator ;  the  introduction  of  a  wax-tipped  catheter 
through  the  sjjeculum  into  the  ureter,  taking  care  to  avoid  any 
contact  of  the  tip  of  the  catheter  with  the  speculum  ;  withdrawal 
of  the  catheter  for  examination  of  any  scratch-marks.  In  a  case 
reported  by  Kelly,  the  dilatation  of  the  ureter  was  sufficient  to 
allow  of  the  passage  of  a  renal  calculus  nearly  half  an  inch  in 
length  by  the  eighth  of  an  inch  wide,  with  tapering  ends.  Here 
the  stone  was  located  lodged  in  the  ureter  behind  the  vesical 
orifice,  and  its  position  was  so  determined  by  vaginal  palpation 
after  demonstration  of  its  presence  by  the  wax-tipped  bougie.'"'' 

Treatment. — During  the  passage  of  a  calculus,  or  when  it  has  first 
lodged  in  the  ureter,  the  treatment  must  necessarily  be  palliative. 
Warm  baths,  constant  fomentations,  packs  of  laudanum  over  the  loin 
and  in  the  course  of  the  ureter,  hypodermic  injections  of  morphia, 
warm  drinks,  periodical  dosage  of  bromide  combined  with  bicarbonate 
of  potassium,  and  piperazine  or  uricidine,  drinks  of  lithia  and  soda 
water,  and  phenacetin  in  small  doses,  may  be  given.  It  is  important 
that  the  bowel  should  be  freely  moved,  and  the  rectum  kept  empty. 
For  this  purpose  calomel  should  be  given,  to  be  followed  by  a  free 
saline  aperient,  or  the  rectum  be  emptied  by  an  enema. 

Ureteral  Fistula — Diagnosis. — '  The  diagnosis  of  ureteral  fistula,' 
says  Kelly,  '  will  be  made  by  noting :  first,  that,  although  there  is  a 
constant  escape  of  urine,  the  patient  still  passes  it  at  regular  in- 
tervals ]  second,  that  upon  injection  of  sterilized  milk  into  the 
bladder,  none  of  it  escapes  through  the  vagina,  while  the  urine  still 
escaping  from  the  vagina  continues  clear  ;  third,  that  by  placing  the 
patient  in  the  dorsal  position  with  elevated  pelvis,  or  in  the  knee- 
breast  position,  the  ureters  may  be  catheterized  as  described,  and 
urine  collected  from  one  side  while  none  escapes  from  the  other ; 
fourth,  that  the  sound  may  be  readily  entered  into  one  ureter  and 
passed  back  to  the  posterior  wall  of  the  pelvis,  while  in  the  other  it 
cannot  be  pushed  in  more  than  a  few  centimetres ;  fifth,  in  the  con- 
genital malformation  where  there  is  a  double  ureter  on  one  side, 
with  one  of  its  openings  near  the  urethra,  and  the  other  in  the 
bladder,  the  evidence  that  the  fistula  is  not  vesical  will  be  obtained 
by  the  injection  of  milk.  The  catheterization  of  both  ureters  will 
demonstrate  also  that  they  are  pervious  and  functionally  perfect.' 

*  Jour,  Amer.  Med.  Ass.,  March  '6,  1900. 


936 


DISEASES   OF   WOMEN. 


Howard  Kelly  thus  describes  the  closure  of  a  fistula  in  the  vault  of  the 

vagina  that  resulted  from  a  vaginal  hysterectomy  : — 

'  The  patient  was  placed  in  the  Trendelenburg  position,  and  an  incision  12 

cm.  long  made  through  abdominal  walls  loaded  with  fat.     After  opening  the 

abdomen,  the  large  fat  omentum  and  in- 
testines were  dislodged  from  the  lower  ab- 
domen and  pelvis  with  great  difficulty,  and 
held  away  by  means  of  cotton  gauze  pads. 

'  The  end  of  the  ureter  could  not  be  found 
on  the  pelvic  floor  on  account  of  the  rigidity 
and  inflammation  surrounding  the  line  of  scar 
tissue  between  the  rectum  and  bladder.  The 
right  ovary  and  tube  were  also  pinned  down 
to  this  scar  tissue  by  numerous  vascular  ad- 
hesions. The  attempt  to  reach  the  ureter  at 
this  point  was  therefore  abandoned,  and  it 
was  sought  out  at  the  pelvic  brim,  where  it 
was  readily  found,  after  lifting  up  the  caput 
coli  and  incising  the  peritoneum  and  pushing 
aside  the  fat.  It  was  then  traced  from  the 
point  of  crossing  the  common  iliac  artery 
down  to  the  pelvic  floor,  exposing  the  whole 
length  of  the  pelvic  portion  by  splitting  the 
peritoneum  over  its  upper  surface.  The  an- 
terior portion  of  the  ureter  was  involved  in 
the  inflammatory  material  surrounding  the 
scar,  which  bled  so  fi-eely  that  no  attempt 
was  made  to  dissect  it  out.  Four  centi- 
metres of  the  length  of  the  ureter  lying 
directly  posterior  to  the  scar  tissue  were  dis- 
sected out,  and  the  ureter  lifted  up  from  its 
bed  and  divided  close  to  the  scar,  sacrificing 
as  little  as  possible  of  its  length. 

'  The  bladder  was  next  dissected  free  from 
its  attachments  to  the  horizontal  rami  of  the 
pubis  on  both  sides  with  scissors  and  fingers, 
and  dropped  down  into  the  pelvis  so  as  to 
extend  it  and  carry  it  more  into  the  back 
part  of  it,  gaining  at  least  3  cm.  in  this  way. 
By  this  means  the  ureter  and  the  bladder 
were  easily  approximated  without  strain.  A 
small  incision  Avas   now  made   through  the 

bladder  wall,  covered  with  fat  at  least  a  centimetre  thick,  at  the  point  on  the 

right  nearest  the  ureteral  end.     This  incision  passed  through  the  peritoneum, 

and  was  not  more  than  3  or  4  mm.  in  length,  and  just  large  enough  to  receive 

the  ureter  snugly. 

'The   under  surface  of  the  ureter  was  then  split  up  for  about  4  mm., 

enlarging  the  calibre  of  its  orifice  to  avoid  a  stricture,  and  a  pair  of  long 


Fig.  601. 

.  Schematic  section  showiug 
the  way  the  ureter  was  held 
by  forceps,  and  the  relation 
of  the  sutures  to  the  coats  of 
tlie  bladder  and  the  ureter. 
All  but  the  raucous  coats  of 
botli  were  included.  3.  The 
appearance  of  the  ureter 
entering  the  opening  in  the 
bladder.  One  suture  laid  in 
place,  but  not  tied.  4.  Shows 
the  snug  union  of  ureter  to 
bladder  after  both  deep  and 
supei-ficial  sutures  were  ap- 
plied. 


AirPj'TfoXs  or  Till:  VuetEUR. 


w.M 


delicate  fol■cell^^  was  introduced  througli  the  urethra  into  the  bladder,  and 
througli  tlic  incision  made  in  its  wall  the  urethral  end  was  drawn  into  the 
bladder,  and  held  there  while  it  was  being  attached  to  the  bladder  wall  by 
about  six  fine  interrupted  silk  sutures,  passed  through  the  muscular  tissue  ot 
the  bladder  and  peritoneal  and  muscular  coats  of  the  ureter  on  all  sides, 
beginning  with  the  under  side. 

'  The  ureter  thus  dissected  out  of  its  bed,  and  attached  to  the  bladder,  was 
stretched  like  a  lax  cord  from  the  posterior  part  of  the  pelvis  to  the  bladder, 
which  lay  gibbous  and  flattened  out  on  the  pelvic  floor. 

'  The  abdominal  incision  was  closed  down  to  its  lower  angle,  where  a 
narrow  gauze  drain  was  inserted  for  fear  of  leakage.     Care  was  taken,  in 


Fig.  602. — The  Field  op  Operation  through  the  Superior  Strait. 

The  bladder  is  freed  from  its  connections  above  and  dislocated  downwards,  and 
on  the  right  side  backwards  to  meet  the  short  ureter.  Its  superior  surface 
is  seen  uncovered  by  peritoneum.  The  angle  in  the  middle  is  the  lower 
terminus  of  the  abdominal  incision  ;  the  extent  of  the  displacement  of  the 
bla  Ider  can  be  estimated  by  this.  Forceps  hold  the  ureter  in  place  until 
the  sutures  are  passed.  A  part  of  the  ureter  is  seen  lifted  up  free  from  the 
pelvic  floor. 

closing  the  incision,  not  to  draw  together  the  peritoneum  underlying  its  lower 
end,  to  avoid  raising  the  bladder  and  indirectly  pulling  upon  the  ureter. 

'  No  leakage  occurred,  the  drain  was  removed,  and  the  wound  healed 
without  suppuration.  The  patient's  urinary  difficulties  were  immediately  and 
completely  relieved  with  the  perfect  restoration  of  continence.' 


Differential  Diagnosis  of  Obscure  Symptoms  by  Means  of 
the  Ureteral  Catheter. 

Kelly  has  repeatedly  drawn  attention,  since  his  earlier  operations  in  1899, 
to  the  value  of  the  renal  catheter  in  determining  the  seat  of  obscure  pain  in 
the  side.  In  the  case  of  stone  in  the  kidney  or  ureter,  the  scratching  of  the 
shining  s-urface  of  the  wax-tipped  catheter  is  seen  under  a  hand  lens  ;  in  the 


938  MSEASES   OF   WOMEN. 


instance  of  stricture,  the  grip  of  the  catheter  is  diagnostic,  while  in  pyelitis, 
the  capillary  haemorrhage,  excited  by  the  touch  of  the  catheter,  is  pathogno- 
monic. More  especially,  however,  he  draws  attention  to  the  assistance  gained 
in  the  differentiation  of  the  pain  caused  by  gall  stone,  renal  calculus,  some 
localized  affection  of  the  colon,  or  appendicitis.  His  method  of  procedure  is 
as  follows  :  The  patient  having  been  placed  in  the  position  mentioned  in  the 
text,  and  the  catheter  introduced,  from  ten  to  fifteen  cubic  centimetres  of  a 
bland  fluid  are  injected  rapidly  into  the  kidney,  distending  its  pelvis  and  pro- 
ducing a  not  too  severe  attack  of  artificial  renal  colic.  The  patient,  locating 
the  pain,  can  say  whether  it  is  in  the  same  position  and  of  the  same  nature 
from  which  she  has  previously  suffered.  He  quotes  some  cases  of  extreme 
interest,  proving  how  this  method  of  examination  enabled  him  to  diagnose 
between  the  conditions  above  enumerated.  A  boracic  acid  solution  was 
employed  for  injection. 

Injuries  to  the  Ureter. 

In  the  various  operations  on  the  uterus  and  adnexa,  especially 
in  cancer  of  the  uterus  involving  the  cervix  and  parametrium,  in 
myomata  spreading  into  or  growing  from  the  broad  ligaments,  in 
the  removal  of  cysts  from  the  latter,  and  in  complicated  adnexal 
tumours  with  extensive  adhesions,  the  ureters  are  liable  to  be 
wounded.  Should  such  an  accident  be  detected  at  the  time  of 
operation,  various  procedures  may  be  followed  to  prevent  the 
disastrous  consequences  which  such  an  act  entails.  Some  surgeons 
still  pei-form  immediate  nephrectomy  of  the  kidney  of  which  the 
duct  is  injured,  and,  in  a  fair  proportion  of  the  cases  reported,  cure 
has  resulted  from  this  step,  although,  in  view  of  the  operations  of 
recent  years,  one  of  these  alternative  procedures  is  certainly  pre- 
ferable, if  it  can  be  carried  out,  to  the  graver  step  of  removing  the 
kidney. 

Sampson*  shows  that,  in  150  hysterectomies,  the  ureters  have 
been  injured  19  times — that  is^  over  13  per  cent.  The  close 
proximity  of  the  ureters  to  the  cervix  and  their  displacement  by 
the  cancerous  growth,  as  well  as  by  the  position  of  the  uterus  and 
the  size  of  the  cervix,  explains  this  danger.  Sampson  considers, 
from  a  study  of  the  parametrium,  that  if  we  desire  to  remove  all 
the  affected  tissue  in  cases  of  cancer  of  the  cervix,  we  should  neces- 
sarily remove  the  ureter.  He,  like  Feitel,  insists  on  the  importance 
of  preserving  the  blood-supply  when  the  ureter  is  dissected  out. 
These  results  materially  affect  the  arguments  for  the  more  extensive 
radical  measures  in  cases  of  cancer  of  the  uterus. 

*  Bulletin  Johns  Ho]ikins  Hospital,  March,  1904. 


AFFECTIONS  OF  THE    UEETERS.  939 


Purcell  *  has  recorded  a  case  in  which,  in  tlie  removal  of  a  hirge  carcinoma 
of  the  uterus,  the  ligatures  ai)plied  to  hoth  uterine  arteries  iiichidcd  the  ureters 
at  eitlier  side,  the  symptoms  of  suppression  of  urine,  together  with  falhng 
temperature  and  sickness,  indicating  the  constriction  of  the  tuhes.  The 
abdomen  was  opened  two  days  after  operation,  and  the  ligatures  were  cut, 
thus  freeing  the  ureters.     The  patient  made  a  good  recovery. 

At  this  time  (1898)  I  collected  the  particulars  from  the  kliniks  of  Martin 
and  Landau  of  Berlin,  also  of  Kufferath  of  Brussels,  as  well  as  from  that  of 
Doyen.  Landau,  out  of  1273  coeliotomies,  abdominal  and  vaginal,  for  cancer, 
myoma,  and  inflammatory  processes,  had  injured  the  ureter  8  times — 1  wound 
closed  spontaneously,  1  was  closed  by  Winckel's  operation,  and  6  were  cured 
by  nephrectomy.  Martin's  statistics  included  2000  abdominal,  and  ,300 
vaginal  operations.  In  these,  of  the  abdominal  there  were  3  cases  of  injury 
to  the  ureter,  and  in  the  vaginal  2.  Of  the  abdominal  cases  he  lost  2 ;  1  from 
septicEemia,  and  1  from  ursemia.  In  all  three  cases  the  abdomen  was  opened. 
In  the  third,  plastic  operations  having  proved  unsuccessful,  nephrectomy  was 
performed.  Kuiferath  had  one  death  in  pan-hysterectomy  from  injury  to  the 
ureter,  none  in  vaginal  hysterectomy,  none  in  ovariotomy  or  oophorectomy, 
one  in  laparotomy  for  a  large  fibroma  in  which  the  m-eter  was  brought  into 
the  abdominal  Avound,  but  nephrectomy  in  this  case  had  subsequently  to  be 
performed.  Doyen  had  one  case  in  vaginal  hysterectomy  for  cancer  of  the 
fundus,  in  which  there  were  post-puerperal  vaginal  cicatricial  bands. 

Since  the  last  edition  of  this  work  was  written  I  have  had  one  fatal  case  in 
which  there  was  at  the  time  of  operation  some  uncertainty  of  a  divided  ureter. 
Tlie  urine  after  operation  was  normal  in  quantity  and  character.  There  were 
no  renal  symptoms.  The  tumour  was  some  fourteen  inches  in  length  and 
reached  to  the  diaphragm.  The  patient  suffered  from  tachycardia.  She 
went  on  fairly  well  for  two  days,  when  sudden  collapse  occurred.  I  opened 
the  abdomen,  and  found  a  rupture  of  the  colon  at  the  left  side. 

Kelly  divides  the  treatment  of  wounded  ureter  under  eight  heads. 
The  first  two  depend  upon  the  principle  of  diverting  the  urine  from 
the  ureter  into  the  bladder  by  creating  an  artificial  vesico-vaginal 
fistula  close  to  the  ureteral  one,  and  directing  it  to  the  opening 
by  either  bridging  over  a  channel  between  the  two  orifices,  or  en- 
circling them  by  a  ring  of  denuded  vaginal  mucosa,  which  latter  is 
folded  on  itself  so  as  to  catch  the  urine  before  it  reaches  the  artificial 
opening.  Again,  the  end  of  the  ureter  is  dissected  out  and  split,  so 
as  to  prevent  contraction,  and  is  then  turned  into  an  opening  made 
in  the  base  of  the  bladder.  Or  the  upper  part  of  the  vagina  is  closed 
after  a  vesico-vaginal  fistula  has  been  formed  near  the  ureteral  one 
in  the  vaginal  vault.  In  incomplete  severance  of  the  ureter,  the 
fistula  is  closed  by  denudation  and  suture.  The  operation  referred 
to  in  the  text  may  be  performed,  or  uretero-cystotomy.     The  vagina 

*  Brit.  Gyn.  Jour.,  Aug.,  1898. 


910 


tjTseases  of  wome^\ 


ruay  be  totally  occluded — total  colpocleisis.     Lastly^  nephrectomy 
may  be  performed/" 

G.  B.  Johnston  t  has  published  an  interesting  case  of  ureter o -ureteral 
anastomosis  for  a  divided  ureter  two  inches  from  the  bladder  end.  The 
operation  was  performed  after  Kelly's  method,  and  the  patient  made  a  com- 
plete recovery. 

Uretero-ureterostomy.l 

Uretero-ureterostomy  by  Van  Hook's  Method. — Briefly,  the 
operation  is  resolved  into  the  following  steps  :  Ligation  of  the  lower 

portion  of  the  tube  one- 
eighth  or  one-fourth  of  an 
inch  from  the  free  end 
with  silk  or  catgut ;  one- 
fourth  of  an  inch  below 
the  ligature,  a  longitudinal 
incision,  twice  the  length 
of  the  ureteral  diameter, 
is  made  in  its  wall.  The 
upper  portion  of  the  ureter 
is  now  incised  from  its 
open  end  for  one-fourth  of 
an   inch.     With    two  fine 


Fig 


603. — Uketeeo-uketebal  Anastomosis. 
(Bloodgood.) 

Traction  suture  tied;  h,  ligated  end  of 
lower  portion ;  c,  c,  fixation  sutures ;  e, 
lower  end  of  upper  segment  implanted  in 
slit  in  lower. 


cambric  needles  a  loop  of  sterilized  catgut  is  carried  through  this  end 
of  the  ureter,  one-eighth  of  an  inch  from  the  extremity,  from  within 
out.  This  loop  firmly  grasps  the  ureter.  The  apertures  through  which 
the  loop  passes  are  one-sixteenth  to  one-eighth  of  an  inch  apart,  and 
equi-distant  from  the  end  of  the  duct.  The  two  needles  now  lie  free, 
and  are  carried  through  the  slit  in  the  side  of  the  lower  end  of  the 
ureter,  passing  through  the  duct-wall  for  half  an  inch  side  by  side, 
and  by  traction  of  the  loop  the  upper  end  of  the  duct  is  drawn  into 
the  lower  portion;  and  thus,  when  the  ends  of  the  loop  are  tied 
securely,  the  transplantation  is  effected  by  the  passage  of  interrupted 
extra-mucous  sutures  which  complete  the  union ;  finally,  the  opera- 
tion being  intraperitoneal,  the  ureter  is  enveloped  in  peritoneum. 

Kelly's  Method.— The  following  instruments  are  needed  :  delicate 
ureteral  tissue  forceps,  fine  scissors,  a  tiny  round  curved  needle 
with  the  eye  open  at  the  end,  delicate  needle  forceps,  as  well  as 
the  guide. 

*  Jour.  Amer.  Med.  Ass.,  March  4,  1899.        t  ^mer.  Gyn.  Jour.,  Jan.,  1903. 
X  See  Ann.  Surg.,  Sept.,  1894,  for  Fenger's  paper. 


AFFECTIONS   OF    THE    I'llETEHs. 


!»41 


Kelly  has  reported  several  cases  of  resection  and  anastomosis  of 
the  divided  ureter.  This  has  been  done  either  for  involuntary  injury 
to  the  ureter,  or  for  a  voluntary  sacrifice  of  the  duct  when  it  passes 
through  a  carcinomatous  mass  in  the  broad  ligament.  Kelly  notices 
in  some  of  the  latter  cases  that  the  ureter  is  dead,  and  that  when 
brought  out  to  the  surface  of  the  body  no  secretion  escapes  from  it. 
Anastomosis  into  the  bladder  Kelly  considers  best  when  the  lower 
end  of  the  ureter  has  been  destroyed,  is  blockaded,  or  inaccessible, 
whereas  anastomosis  of  the  ureter  into  itself  is  best  adapted  for 
joining  the  divided  ends  in  the  posterior  part  of  the  pelvis  between  the 
pelvic  brim  and  the  broad  ligament.  He  has  constructed  a  special 
ureteral  guide,  and  he  thus  gives  his  method  of  making  the  anasto- 
mosis :  '  A  fine  silk  mattress-suture  is  passed  through  the  under 
surfaces  of  the  cut  ends  and  tied,  bringing  them  snugly  together.     A 


Fig.  604. — Ueetekal  Gcide  op  Howakb  Kelly. 

Half  size,  the  handle  being  attached  at  an  angle,  and  flush  with  one  end.  The 
head,  or  guiding  part,  is  4  cm.  long,  cylindrical,  and  rounded  at  the  free 
end  like  the  end  of  a  cartridge ;  near  the  end  is  a  groove  in  which  to  tie 
the  ureter  to  fix  it  during  the  anastomosis. 


longitudinal  slit  is  then  made  in  the  upper  part  of  the  ureter  2  cm. 
distant  from  the  end,  just  large  enough  to  admit  the  guide  easily. 
The  rounded  end  of  the  guide  is  then  pushed  through  the  slit  into  the 
ureter,  down  through  its  open  end  and  well  into  the  lower  end,  where 
it  is  loosely  tied  behind  the  swelling  at  the  head  to  hold  it  in  place 
during  the  passage  of  the  rest  of  the  sutures  (Fig.  60i).  The  end-to- 
end  anastomosis  is  now  completed  by  passing  fine  silk  sutures,  either 
interrupted  or  mattress^  with  the  sides  very  close  together,  at 
intervals  from  1  to  H  mm.,  including  all  the  coats  except  the  mucosa. 
During  the  suturing  the  ureter  can  be  rotated  from  side  to  side  by 
removing  the  handle  of  the  guide.  At  the  completion  the  string 
tied  round  the  lower  end  of  the  guide  is  cut, and  the  guide  withdrawn.' 
The  success  of  the  suturing  may  be  tested  by  the  injection  of  a  little 
water  through  the  cup,  and  seeing  that  there  is  no  leakage  at  the 


94:2  DISEASES   OF   WOMEN. 

junction  where  the  ends  are  joined.     The  slit  which  has  been  made 
is  now  closed  by  silk  sutures. 

Uretero-cystotomy. — Wesley  Bovee,  in  a  critical  survey  of  ure- 
teral implantations,  presented  a  table  of  28  ureteral  cystoscopies 
for  injury  to  the  ureters  during  abdominal  operations,  and  42 
others  for  uretero-vaginal  and  other  fistulas  and  abnormalities. 
This  was  in  1900.  At  the  meeting  of  the  American  Gynaecological 
Society,  in  May,  1903,  he  had  collected  38  more  cases,  which,  with 
3  of  his  own,  made  a  total  of  111  cases.  He  shows  that  Tauffer, 
in  1877,  had  performed  the  first  uretero-cystoscopy."'  In  Bovee's 
first  case,  the  left  ureter  was  ligated  and  cub  off  at  its  junction  with 
the  bladder  in  an  operation  for  carcinoma  of  the  cervix,  the  duct 
being  subsequently  grafted  into  the  bladder.  Two  inches  of  the 
ureter  had  been  removed.     Bovee  describes  the  operation  thus  : — 

'  A  small  opening  was  made  in  the  bladder  slightly  below  its  separation  from 
the  uterus  above,  and  the  ureter  grafted  into  it.  This  was  done  by  holding 
the  end  of  the  ureter  in  proper  place  by  means  of  a  pair  of  forceps,  passed 
into  the  bladder  through  a  second  opening  at  the  fundus.  The  suturing  was 
done  with  catgut,  no  sutures  entering  mucosa.  A  second  layer  of  interrupted 
silk  sutures  drew  the  bladder  up  over  the  ureter  like  a  cuff.  A  small  opening 
into  the  ureter  an  inch  above  the  bladder  was  accidentally  made  during  the 
operation  and  closed  with  three  interrupted  No.  1  silk  sutures.  At  the  time 
it  was  not  decided  that  this  opening  penetrated  the  whole  of  the  ureteral  wall. 
The  rectum  and  bladder  were  sutured  together  above  the  new  uretero-cystic 
junction,  and  vaginal  gauze  and  bladder  drainage  established.  As  leakage  of 
urine  occurred  subsequently,  six  months  later  a  second  operation  was  per- 
formed, and  after  separation  of  dense  adhesions  connecting  the  bladder  and 
intestines,  a  transverse  opening,  1|  inches  in  length,  was  made  in  the  top  of 
the  bladder  for  further  exploration.  The  small  opening  of  the  left  ureter  was 
now  found  from  the  inside  of  the  bladder,  but  was  considered  too  small  for 
practical  use.  A  separate  opening  was  found  in  the  bladder  which  was  con- 
nected with  a  fistula  passing  upward  to  a  small  opening  in  the  m-eter,  probably 
the  one  sutured  at  the  last  operation,  and  downward  to  the  vagina.  The  ureter 
was  severed  just  above  the  fistula,  and  reimplanted  into  the  bladder  by  means 
of  catgut  and  silk  interrupted  sutures.  The  surrounding  tissues  were  also 
carefully  sutured  to  the  bladder  wall  for  reinforcement.  The  tiansverse 
bladder  incision  was  now  closed  with  a  continuous  catgut  suture.  The  fistula 
into  the  vagina  was  enlarged,  and  a  strip  of  iodoform  gauze  passed  through  it 
for  purposes  of  drainage,  should  leakage  occur. 

'in  a  second  case,  after  a  long  and  tedious  operation  for  carcinoma  of  the 
cervix,  in  which  1\  inches  of  ureter  was  sacrificed,  the  operation  failed,  and 
a  second  operation  of  the  following  nature  was  done. 

'  A  new  opening  was  made  in  the  bladder,  the  ureter  sej)arated  for  a  distance 
of  about  1|  inches,  and  its  end  split  into  two  equal  flaps  J  inch  in  length,  and 

*  Deutsch.  Med.  WcJino..  ]S77,  p.  438. 


AFFECTIONS   OF   THE    URETERS.  '.i43 

these  ends  brought  into  the  bladder  through  a  second  opening.  Here  they 
were  sutiirod  at  points  about  three-qnavters  of  an  inch  from  the  bladder 
opening,  the  catgut  sutures  passing  conii)letelytlirough  the  ureter  and  bladder 
walls  and  being  tied  on  the  outside.  The  opening  in  the  bladder  about  the 
ureter  was  then  closed,  and  the  bladder  drawn  well  up  over  the  ureter  by 
a  few  interrupted  sutures.  Previous  to  this  the  bladder  had  been  in  part 
loosened  from  its  lateral  attachments,  and  drawn  upward  and  backward  in 
the  pelvis.  The  other  bladder  opening  w-as  now  closed,  and  vaginal  gauze 
drainage  established.' 

The  i-esult  so  for  was  satisfactory.  The  third  case  was  one  in  which  a 
uretero-vaginal  fistula  followed  hysterectomy  for  fibro-myoma.  Transperi- 
toneal uretero-cystotomy  was  performed  two  years  and  six  months  sub- 
sequently, under  very  difficult  surroundings. 

Bovee  raises  the  question  whether  this  operation  should  be  done 
a  few  months  after  the  radical  operation  for  cancer.  Eight  to 
twelve  months  without  recurrence  should  elapse.  Sampson  goes 
so  far  as  to  propose  that  uretei'o-cystotomy  should  be  performed  on 
both  sides  as  a  preliminary  step  in  radical  operation  for  cancer  of 
the  uterus.  The  indications  for  the  operation  are — uretero-vaginal 
fistula  arising  from  any  cause,  such  as  tuberculosis  of  the  lower 
portion  of  the  ureter,  the  erosions  from  ureteral  calculi,  traumatisms, 
syphilis,  etc.  ;  also  abnormal  ureteral  orifices. 

Bovee,  like  Feitel  and  Sampson,  attributes  certain  ureteral  lesions  to 
interference  with  the  blood  supply  of  the  lower  portion  of  the  ureter.  Should 
a  lesion  be  in  the  lower  two  inches  of  the  duct,  resection,  with  bladder  graft- 
ing of  the  proximal  portion,  is  beyond  all  doubt  the  best  operation.  Lesions 
above  the  ilio-pectineal  line  that  are  not  amenable  to  drainage  or  suture, 
demand  uretero-ureteral  anastomosis  when  less  than  two  inches  of  the  duct 
has  to  be  sacrificed.  ]f  more  than  this  must  be  excised,  especially  if  the 
lesion  be  near  the  iliac  bifurcation,  he  considers  that  implantation  into  the 
fellow  duct  would  probably  be  the  best  step  to  take.  Should  the  ureter  be 
injured  very  high  up  in  the  abdomen,  Bovee  suggests  the  plan  which  he  has 
earned  out  successfully  on  dogs,  of  loosening  and  depressing  the  kidney  so  as 
to  allow  union  of  the  ureteral  ends.  Bovee  does  not  approve  of  vaginal 
plastic  operations  as  substitutes  for  uretero-cystotomy. 

The  routes  by  which  the  operation  may  be  carried  out  are  extra-peritoneal, 
intra-perituneal,  trans-peritoneal,  sacral,  and  infra-puljic.  The  sacral  and 
infra-pubic  routes  for  practical  purposes  may  be  dismissed  from  consideration. 
Veit  and  Witzel's  plan  has  the  advantages  of  suflicient  working  space  and 
rapidity  in  finding  the  ureter  and  of  making  the  implantation.  If  there  be 
considerable  urinary  infection  the  extra-peritoneal  route  must  be  chosen ; 
otherwise  the  ureter,  if  the  infection  be  only  slight,  may  be  temporarily 
ligatured  at  a  point  above  the  proposed  vesical  junction.  The  field  of  opera- 
tion on  the  ureter  and  bladder  should  be  kept  well  outside  the  peritoneum. 
By  folding  the  peritoneum  over  the  ureter,  a  support  and  sufficient  blood 


944  DISEASES   OF   WOMEN. 

supply  are  secured,  and  extra-peritoneal  drainage  is  permitted.  Of  course 
such  a  typical  technique  cannot  be  carried  out  after  extensive  pelvic  opera- 
tions reaching  antro-posteriorly  as  well  as  latterly.  The  implantation  should 
be  made  as  oblique  as  possible ;  and  the  point  in  the  bladder  wall  most 
favourable  is  that  in  its  side,  fairly  well  up.  The  slit  should  be  about  three- 
quarters  of  an  inch  in  length,  and  the  ureter  sutured  into  it  the  whole  length. 
The  end  of  the  duct  should  be  slit  half  an  inch  on  two  opposite  sides,  and 
each  flap  sutured  to  the  inner  side  of  the  bladder  wall  beyond  the  farther  end 
of  the  bladder  slit.  The  absorbable  sutures  are  passed  through  the  bladder 
wall  and  the  flap.  It  is  unnecessary  to  denude  the  bladder  of  mucosa,  or  to 
leave  the  ureteral  mucosa  out  of  the  bite  of  the  suture,  which  latter  will  sink 
into  the  mucosa  sufficiently  to  prevent  incrustation  forming  upon  it.  The 
flaps  are  secured  by  sutures  tied  on  the  outside  of  the  bladder,  and  the  ureter 
is  sutured  in  the  bladder  slit  by  fine  catgut  or  kangaroo  tendon  sutures,  placed 
closely  together,  but  not  penetrating  the  ureteral  mucosa.  Finally,  a  row  of 
sutures,  interrupted  or  continuous,  is  carried  into  the  bladder  so  as  to  bring  a 
fold  over  the  whole  of  the  incision.  The  technique  is  rendered  easier  by  a 
free  incision  in  the  top  of  the  bladder  to  be  closed  subsequently  to  its  com- 
pletion. Bovee  recognizes  the  work  done  in  the  different  operative  procedures 
by  Colzi,  Mackenrodt,  Baumm,  Fritsch,  Kelly,  Krause,  Kayser,  Calderiui,  and 
especially  that  of  Van  Hook. 

Complete  Nephro-ureterectomy  in  Tuberculosis  of  the  Kidney. — 
Wesley  Bovee,  who  credits  Howard  Kelly  with  being  the  first  to 
perform  the  operation  of  nephro-ureterectomy,*  in  cases  of  tuber- 
cular disease  of  the  kidney  advocates  complete  nephro-ureterectomy. 
In  82  per  cent,  of  cases  the  operation  is  done  for  tubercular  disease. 
'  Under  no  consideration,'  he  says,  '  will  this  operation  be  justified 
until  the  condition  of  the  opposite  kidney  be  learned,  except  when 
the  function  of  the  kidney  involved  is  beyond  doubt  permanently 
suspended.'  This  conclusion  can  only  be  arrived  at  by  careful 
comparative  analysis  of  the  secretion  of  hoth  kidneys. 

Independently  of  tuberculosis,  the  conditions  calling  for  complete 
nephro-ureterectomy  are — malignant  disease  of  the  ureter,  severe 
traumatic  injury  throughout  most"  of  the  course  of  the  duct,  and 
multiple  marked  ureteral  stricture  from  ureteritis.  Regarding  which 
method  should  be  followed,  Bovee  gives  preference  to  the  operation 
being  begun  by  the  vaginal  route,  the  extra-peritoneal  loin  route 
for  extirpation  of  the  kidney  and  upper  portion  of  the  ureter  follow- 
ing. He  prefers  the  method  of  Montgomery,  by  means  of  which 
the  ureter  is  first  freed  and  ligated  per  vaginam  from  the  broad 
ligament.f 

*  ^mer.  Gyji.,  April,  1903. 

t  This  communication  of  Bovee's  should  be  read  in  its  entirety. 


CHAPTER   XLVII. 
AFFECTIONS   OF    THE    KIDNEY. 

The  Kidney  in  its  Relation  to  Gynajcolog'y. 

The  tendency  to  fall  into  error  by  OA^erlooking  a  renal  tiuid  accu- 
mulation or  solid  growth  when  making  an  abdominal  examination, 
has  to  be  borne  in  mind.  There  are  many  practical  points,  of  the 
greatest  importance,  bearing  on  the  special  relation  of  renal  disease 
to  aftections  of  the  pehic  organs  in  women.  This  remark  applies 
more  particularly  to  displacements,  enlargements  due  to  neoplastic 
formations,  cystic  growths,  distension  with  water  or  pus,  or  malignant 
disease. 

With  the  view  of  emphasizing  the  need  for  a  recognition  of  the 
care  required  in  differentiating  certain  affections  of  the  kidney 
from  disorders  of  the  pelvic  viscera,  I  include  a  short  chapter  on 
affections  of  the  kidney  in  this  work. 

Our  knowledge  of  the  pathology,  symptomatology,  and  treatment  of  the 
urinary  organs  has  been  of  late  years  considerably  advanced  through  the 
original  work  of  such  men  as  Howard  Kelly,  Edebohls,  Christian  Fenger,  and 
Bovee  in  America,  while  at  home  the  writings  of  Henry  Morris,  Mayo  Eobson, 
Greig  Smith,  Knowsley  Thornton,  and  Jacobson  have  done  much  in  the  same 
direction. 

The  Bulletins  of  Jolins  Hopkins  Hospital,  ani.  the  Annals  of  Surgery,  con- 
tain accurate  and  full  information  with  regard  to  the  operative  procedures  of 
our  American  confreres. 

Differentiation  and  Diagnosis  of  Renal  Enlargements. 

Those  forms  of  renal  enlargement  which  we  are  most  likely  to 
confound  with  affections  of  the  pelvic  viscera  in  women,  are  not 
so  much  those  which  have  associated  with  them  marked  renal 
symptoms,  or  acute  intiammatoiy  conditions  and  their  consequences, 
as  the  enlargements  or  secondary  outgrowths  from  the  organ  which 
may  be  present  without  causing  pain  or  any  distinct  renal  symptom. 
Such  are  simple  cysts  or  hydatid  cysts,  hydro-nephrosis,  mobile  and 
movable  kidney,  and  such  tumours  as  the  fibromata  and  lipomata. 

3   p 


946  DISEASES   OF   WOMEN. 

Still,  such  conditions  as  pyonephrosis  and.  peri-nephric  abscess  have 
been  not  infrequently  confounded  with  ovarian  cystoma.  Errors 
are  still  more  likely  to  be  fallen  into  if  there  be  associated  with 
the  kidney  affection  any  disease  of  the  appendix  or  the  uterine 
adnexa,  more  particularly  should  this  latter  involve  the  ureter. 
Those  cases  are  very  difficult  to  differentiate  in  which  there  is 
evidence  by  urinary  analysis  or  local  symptoms  of  kidney  implica- 
tion, at  the  same  time  that  enlargement  of  the  adnexa  of  the  corre- 
sponding side  is  detected,  and  in  some  of  these  cases  nothing  save 
exploratory  incision  of  the  kidney  will  settle  the  doubt  as  to  the 
presence  of  pus  or  calculus.  In  cases  in  which  palpation  of  the 
kidney  does  not  lead  to  the  discovery  of  a  cavity,  or  calculus,  no 
exploration  of  the  kidney  is  satisfactory  in  which  j)unctures  with 
the  exploratory  needle  are  not  made. 

Landmarks  of  the  Renal  Region. 

In  examination  of  the  kidney  by  palpation,  we  have  to  remember  the 
different  relations  of  tlie  right  and  left  viscus.  We  may  accept  as  sufficiently 
accurate  for  defining  the  position  of  the  kidney,  the  lower  border  of  the 
eleventh  rib,  and  the  middle  of  the  third  lumbar  spine,  the  situation  of  the 
hilum  being  marked  by  the  level  of  the  first  lumbar  vertebra.  While  the  right 
kidney  is  in  close  relation  to  the  under  surface  of  the  liver  above,  and  has  the 
duodenum  and  hepatic  flexure  of  the  colon  lying  in  front  of  it  (the  duodenum 
almost  invariably  resting  upon  its  anterior  surface),  the  superior  border  of  the 
left  organ  touches  the  fundus  of  the  stomach,  and  for  its  upper  two-thirds  its 
outer  border  is  in  relation  with  the  spleen.  Anteriorly,  and  along  the  inner 
border  of  the  left  organ,  is  the  pancreas,  the  descending  colon  lying  over  its 
anterior  surface  below.  Such  connections  show  how  difficult  it  is  always  to 
isolate  the  kidney  when  there  are  morbid  conditions,  displacements,  or  enlarge- 
ments of  the  surrounding  viscera,  and  its  comparative  immobility,  as  pointed 
out  by  Cunningham  and  Kendal  Franks,  while  due  partly  to  its  shape,  is  also 
dependent  upon  the  indirect  pressure  exercised  on  its  surface  by  these  viscera. 
The  mobility  of  the  kidney  is  influenced  hx  the  amount  of  fatty  tissue  \>y  which 
it  is  enveloped.  The  postei'ior  surface  of  the  kidney  exhibits  three  well- 
marked  areas,  which  correspond  respectively  to  the  psoas  internally,  to  the 
quadratus  lumborum  externalh^,  and  to  the  diaphragm  above. 

I  have  thus  briefly  recalled  the  positions  and  surroundings  of  the  kidnej's,  in 
order  that  the  reader  may  bear  these  well  in  mind  in  making  a  manual 
examination  of  the  organ.  It  must,  however,  be  remembered  that  in  a  large 
proportion  of  cases  the  kidney  cannot  be  felt  below  the  margin  of  the  ribs. 
Xoble  states  that  in  three-fourths  of  the  cases  examined  by  him  the  kidney 
could  not  be  palpated.  This,  however,  may,  as  he  saj's,  depend  upon  the 
difficult}^  of  detection  of  the  lower  margin  of  the  kidney  in  a  clinical 
examination.  x\nother  practical  point  to  remember  is  that  the  kidney  moves 
slightly  in  inspiration,  descending  with  the  descent  of  the  diaphragm. 


AFFECTIONS  OF  THE  KIDNEY. 


947 


The  possibility  of  a  horse-shoe  kidney  being  present  has  to  be  remembered. 
Such  a  kidney  (Fig.  G05'   I  removed  when  Demonstrator  in  tiie  anatomical 

room  of  Queen's  College,  ( 'oik.  There 
was  also  abnormal  position  of  the 
great  vascular  trunks. 


A. 

Fig.  tjO.j.* — A,  Huk.->e-su(  .e  Kioney. 
The  ureters  arc  dissected  up,  showing  the  brauching  of  the  ducts  before  uniting 

to  form  the  ureters.     They  are  seen  emerging  separately  from  Ihe  anterior 

surface  of  the  kidney. 
B,  Posterior  Surface  of  EaoxEy,  detached  from  the  Vascular   Coxsec- 

Tioxs,  showing  the  Grooves   for  the   Aokta   axd  Yexa   Cava   axd    a 

Cystic  Cavity. 
a,  aorta  and  vena  cava  ;  h,  renal  arteries  and  vein  ;  f,  (7,  ureters  ;/,  cyst ;  g,  e.  renal 

arteries  divided :  h,  small  vein.     The  aorta  and  vena  cava  curved  suddenly 

to  the  right,  consequently  altering  the  course  and  direction  of  the  iliac  vessels. 

Examination  of  the  Kidney  by  Palpation. 
The  kidney  may  be  palpated  with  the  patient  in  three  different 
positions — in  the  dorsal  pjsition,  with  the  head  and  trunk  well 
raised;  in  the  prone,  bending  forwards  over  the  end  of  a  couch;  or 
standing.  In  cases  of  doubt  and  difficulty  it  is  well  to  examine  in 
all  three  positions.  If  in  the  dorsal  position,  one  haad  is  carried 
under  the  renal  region,  and  the  other  is  placed  over  it  in  front  on 
the  abdomen.     By  deep  pressure  and  movement  of  the  lingers,  laid 

*  Duh.  Quar.  Jour.  vol.  xlii.  p.  541.  Such  a  form  of  kidney  was  first  described 
by  Rokitansky.  In  that  illustrated  in  the  text  there  was  absolute  fusion  of  the 
two  organs  into  one,  mir  was  any  anatomical  demarcation  indicative  of  original 
cleavage  present. 


048  DISEASES   OF    WOMEN. 


tiat  on  the  abdominal  wall,  an  enlargement  or  tenderness  may  be 
detected.  This  is  further  facilitated  by  making  the  patient  turn  a 
little  towards  either  side.  While  she  is  lying  on  her  back,  it  is 
advisable  to  carry  a  hand  behind  each  kidney,  and,  by  simultaneous 
and  alternate  pressure,  relatively  to  gauge  any  difference  in  size 
which  may  exist. 

In  the  second  position,  the  patient  leans  forward  over  the  end  of 
a  fairly  high  couch,  the  waist  being  supported  by  a  firm  pillow. 
The  renal  region  of  both  sides  is  bimanually  palpated.  In  the  third 
position,  the  patient,  who  is  standing,  leans  slightly  forward,  with 
the  hands  resting  on  a  table,  and  the  lumbar  regions  are  then 
examined  as  in  the  other  methods.  The  principal  swellings  at  the 
right  side,  which  have  to  be  borne  in  mind  as  likely  to  be  mistaken 
for  enlargements  of  the  kidney,  are — a  duodenal  tumour,  a  distended 
gall-bladder,  an  omental  tumour,  disease  in  the  hepatic  flexure  of 
the  colon,  impacted  fseces,  and  a  pyloric  growth ;  at  the  left  side, 
splenic  enlargement,  an  omental  tumour,  or  disease  of  the  descend- 
ing colon.  I  have  already  instanced  two  cases  of  hepatoptosis 
which  were  mistaken  for  enclosed  and  movable  kidney  (p.  44). 

Causes  of  Renal  Enlargement.* 

It  is  well  in  ihe  first  place  to  enumerate  the  principal  sources  of  pelvic 
enlargement. 

Fluid  Enlargements — 

Hydro-nephrosis. 
Pyo-nepbrosis. 
Kenal  abscess. 
Peri-nephric  abscess. 

Suppurative  nephritis  i  t5     i      '    t,  •.• 
^  '^  ^  i  Pyelo-nepnntis. 

Tubercular  kidney. 

Simple  cysts.  ■ 

Hydatid  cysts. 

Any  of  these  conditions  may  be  complicated  with  calculus  in  the  kidney  or 
ureter,  or  obstruction  in  the  latter. 


Simple  Neoplasms- 


Fibromata 
Lipomata 


Inflammatory  ; 
Simple  ; 

Cystic ; 
Muscular ; 
Fatty. 


See  Knowoley  Thornton'^.' Harveian  Lectures,'  1889. 


AFFECTIONS   OF   THE   KIDNEY.  049 


Haematangiomata. 

Osteomata. 

Adenomata  ...  {  ^, ,'     '  -  ' 

I  (jrJanclular, 

Malignant  Neoplasms  — 

Sarcomata  (various  kinds). 
Lymph  adenomata. 
Carcinoraata  (various  kinds). 

Hydro-Nephrosis  (congenital  or  acquired) — 

Is  a  distension  of  the  kidney  with  fluid  caused  by  obstruction  to  the 
flow  of  urine.     (Liable  to  be  confounded  with  ovarian  cystoma.) 
Pyo-Nephrosis — 

Hydro-nephrosis,  accompanied  by  suppuration.     (Very  liable  to  follow 
calculus  or  traumatic  puncture  of  the  hydro-nephritic  cyst ;  maj' 
cause  cystitis.) 
Benal  Atscess — 

Generally  the  result  of  injury,  calculus,  or  foreign  body  ;  or  it  maj' 
follow  the  administration  of  such  drugs  as  cantharides  or  turpentine. 
Peri-Nephric  Abscess — 

Abscess  in  the  cellular  bed  outside  the  kidney,     (a)  Primary  and 
independent  of  the  kidney ;   (6)  secondary  to  suppurative  nephritis, 
renal  abscess,  or  pyo-nephrosis ;  (c)  secondary  to  renal  fistula  and 
urinary  extravasation  and  calculus. 
Suppurative  Nephritis — ■ 

Suppurative  inflammation  of  the  kidney,  either  of  its  pelvis  (pyelitis) 
or  of  the  entire  organ   'pyelo-nephritis).     It  is  usually  a  secondary 
and  acute  inflammation,  attacking  both  kidneys,  and  rapidly  fatal. 
Tubercular  Kidney — 

Tubercular  degeneration  of  the  kidney — generally  both  organs — end- 
ing frequently  in  abscesses  (pyelitis  or  nephritis).     The  ureter  and 
bladder  are  often  involved. 
Simple  Cysts — 

Spring  from  the  cortex  ;  contents  vary  in  character  ;  serous,  albumin- 
ous, or  of  a  colloid  nature  ;  do  not  contain  urine. 
Hydatid  Cysts — 

G-enerally  originate  in  the  renal  tissue  ;   occasionally  from  the  sub- 
capsular cellular  tissue.     Maj^  assume  large  size,  and  be  mistaken 
for  ovarian  cystoma. 
Fibroma — 

A  renal  fibroma  may  assume  an  enormous  size.     Bilrotb  removed  one 
weighing  40  lbs.,  and  Spencer  "Wells  two  fibro-lipomata  weighing 
l6i   lbs.  and    14^  lbs.  respectivelj'.     They  may  degenerate    into 
fibro-cystomata  or  fibro-lipomata. 
Lipoma — 

Originates  in  tlie  adipose  areolar  tissue,  and  forces  its  way  into  the 
hilum  of  the  kichiey. 
Haematangioma  and  Osteoma — 
Verv  rare. 


950  DISEASES   OF   WOMEN. 

Adenoma — 

(a)  Papillarj^ — more  common  as  originating  in  the  tubules  and 
Malpighian  capsules ;  (h)  Glandular — more  frequent  in  the  cortex. 
(Knowsley  Thornton  described  a  kidney  "which  was  affected  with 
calculus  and  papilloma  of  the  pelvic  end  of  the  ureters,  causing 
hydro-nephrosis.) 
Sarcoma — 

In  accounting  for  the  recurrence  (after  removal)  and  malignancy  of 
sarcoma  of  the  kidney  in  children,  and  its  non-malignancy  in  the 
adult,  Thornton  says — 

'  The  difference  is  to  be  sought  in  the  varieties  of  sarcoma  most 
common  in  early  life,  and  in  the  adult;  and,  secondly,  in  the  portion 
of  the  organ  first  invaded  by  the  disease.'  In  children  he  notices 
the  prevalence  of  the  cell  element  approaching  the  embryonic  type  ; 
the  intercellular  substance  is  soft  and  full  of  fluid.  In  the  adult 
there  is  less  of  the  cellular  and  much  more  abundant  intercellular 
tissue,  which  is  dense  and  hard,  and  of  slower  growth,  the  capsule 
alone  being  commonly  attacked,  while  in  children  the  entire  renal 
substance  is  infiltrated. 
Lymphadenoma — 

Is  accompanied  by  evidence  of  the  disease  elsewhere. 
Carcinoma — 

Encephaloid  is  the  form  most  frequently  met  with  ;  next,  scirrhus ; 
and,  lastly,  colloid. 

Cysts  of  the  Kidney. 

Goelet  diAddes  cysts  of  the  kidney  into  serous,  hydatid,  paranephric,  and 
polycystic.  Serous  cj^sts  are  found  frequently  in  women.  They  originate  in 
the  cortex,  often  assume  a  large  size,  and  occasionally  communicate  with  one 
of  the  calyces.*  It  is  important  to  remember  the  size  to  which  these  cysts 
may  grow,  as  they  have  not  infrequently  been  confounded  with  ovarian  cysts. 
Their  contents  may  have  no  trace  of  urinary  ingredients,  and  are  usually 
clear  or  straw  coloured,  though  there  may  be  an  extravasation  of  blood 
within  the  cyst.  The  function  of  the  affected  kidney  may  not  be  disturbed. 
Their  growth  is  slow.  The  treatment  resolves  itself  into  removal,  incision, 
and  drainage,  or  nephrectomy  may  have  to  be  performed.  The  condition 
of  the  other  kidney  must  be  first  ascertained. 

Diagnosis  and  Treatment  of  Hydatid  Cysts.- — Hydatid  cysts  of  the  kidney 
may  give  rise  to  but  little  trouble.  As  in  the  case  of  the  liver,  the  echinococ- 
cus  may  find  its  way  into  the  stomach  and  intestines  through  tlie  food. 

In  the  case  of  a  large  hydatid  cyst  of  the  liver,  which  I  have  just  success- 
fully operated  upon,  the  cyst  held  six  pints  of  hydatid  fluid,  which  was 
full  of  booklets,  there  being  but  one  large  daughter  cyst,  which  I  managed  to 
extract  entire  through  the  incision.  There  was  httle  doubt  that  the  mode  of 
conveyance  was  through  the  patient's  constant  habit  of  fondling  a  pug  dog. 
In  this  case  there  were  absolutely  no  symptoms  up  to  a  few  weeks  prior  to 

*  Ann.  Gyn.  and  Perl.,  Sept.,  1903. 


AFFECrrONS   OF    TffF    KfDNET.  it51 


the  time  of  operation,  when  the  upper  pressure  on  the  lungs  caused  great 
pain,  ultimately  becoming  agonizing.  The  patient  was  thought  in  the  first 
instance  to  be  sullcring  from  neuralgia  and  muscular  rheumatism.  The  cyst 
was  discovered  tlu'ough  an  exploratory  incision.  The  patient  has  now  quite 
recovered  from  the  operation,  but  there  is  still  a  very  contracted  sinus,  which 
will,  I  trust,  close  in  time. 

Hydatid  cysts  of  the  kidney  may  rupture  into  its  pelvis,  or  into  the  lung  or 
intestine.  The  contents  of  the  cyst  may  find  their  way  into  the  urine, 
obstruct  the  ureter,  and  cause  C}  stitis.  Though  the  cyst  may  disappear  after 
rupture,  this  is  not  a  likely  termination,  and  if  there  be  no  interference  a 
fatal  result  must  follow  from  the  rupture  andsuppm-ation.  When  discovered, 
the  cyst  must  be  exposed  and  removed  if  possible,  the  healthy  portion  of 
kidney  being  preserved,  and  the  cavity  closed  with  fine  cumol  gut  sutures. 
If  the  cyst  be  not  removable,  the  best  course  to  pursue  is  to  incise  and  empt\' 
it,  and  attach  its  margins  to  those  of  the  lumbar  incision.  A  drainage  tube  is 
inserted,  and  the  cavity  is  aspirated  daily  with  a  weak  iodine  or  formalin 
solution  until  it  contracts  sufficiently  to  omit  drainage  and  permit  closure  of 
the  contracted  canal.  Under  any  circumstances,  should  there  be  a  suspicion 
of  a  hydatid  in  the  kidney,  and  serious  symptoms  due  to  rupture  and  suppura- 
tion or  obstruction  of  the  ureter  be  present,  immediate  interference  is  demanded, 
and  an  incision  into  the  cyst  should  be  made. 

Hydatid  Cyst  of  the  TJterus  treated  by  Incision  and  Marsupialization. — 
Barette  *  operated  on  a  patient,  aged  21,  for  an  abdominal  tumour,  which 
reached  above  the  umbilicus,  and  was  rapidly  growing  and  causing  pyrexia. 
After  opening  the  abdomen  and  incising  the  reddish  smooth  wall  of  the 
tumour,  which  resembled  uterine  tissue,  about  three  and  a  half  litres  of 
yellowish  fluid  escaped,  containing  ovoid  flask-shaped  masses  resembling  half 
collapsed  grapes.  As  the  wall  of  the  cyst  could  not  be  dissected  out  on 
accoimt  of  its  intimate  connection  with  the  uterine  tissue,  its  edges  were 
carefully  sutured  to  those  of  the  abdominal  incision,  the  cavity  was  cleansed 
and  plugged,  and  four  drains  were  inserted. 

The  result  was  extremely  good.  The  pouch  grew  gradually  smaller,  and 
the  lining  membrane  became  detached  in  small  pieces.  The  drains  were 
removed  at  the  end  of  eighteen  days,  and  the  cicatrization  of  the  wound  was 
complete  in  two  months.  Further  examination  of  the  fluid  which  escaped 
showed  that  it  was  manifestly  a  hydatid  cyst.f 

I  have  thus  summarized  the  different  enlargements  of  the  kidney 
ia  order  to  impress  on  the  reader  the  necessity  for  being  on  his  guard 
in  arriving  at  a  diagnosis  in  some  cases  of  obscure  abdominal  tumour, 
and  still  more  so  in  cases  in  which  the  nature  of  the  disease  seems  at 
first  sight  obvious.  Remembering  that  hepatic  and  renal  tumours 
may  both  complicate  and  simulate  ovarian-uterine  tumours,  he  must 
not  forget  so  to  investigate  all  suspicious  oases  as  to  eliminate  those 
sources  of  error  that  might  perhaps  lead  up  to  a  useless  or  fatal 
laparotomy.  In  the  instance  of  the  liver,  the  evidences  of  hepatic 
*  Sem.  Med.,  July  11,  1900.  t  Jellett,  Brit.  Gijn.  Jour.,  Nov.,  1900. 


952  DISEASES   OF    WOMEN. 


disease  {vide  chapter  on  '  Ovarian  Tumours  ')  are  to  be  sought  for  in 
the  area,  site,  and  connections  of  the  tumour  ;  icterus  ;  emaciation  ; 
sickness ;  constipation  ;  and  ascites.  In  the  case  of  the  kidney,  we 
must,  in  addition  to  the  local  and  constitutional  evidences  of  renal 
disorder,  most  carefully  examine  the  urine  for  the  presence  of 
albumen,  pus,  mucus,  or  debris  of  renal  tubes  and  epithelium. 

Diagnosis  of  Tumours  of  the  Liver  and  Hepatoptosis  from  Renal 
Tumours  or  Movable  Kidney. 

The  examination  of  the  urine  drawn  direct  from  the  kidney  by 
renal  catheterization,  when  this  can  be  effected,*  is  the  most 
certain  method  of  diagnosis  in  differentiating  kidney  from  bladder 
and  disease  of  one  kidney  from  the  other. 

I  have  already  referred  (p.  45)  to  a  case  of  obscure  abdominal  tumour 
complicating  a  uterine  afiection,  in  which  nephrectomy  of  a  movable  kidney 
was  performed  for  carcinoma ;  and  to  two  other  cases  (p.  44)  in  which 
hepatoptosis  was  mistaken  for  an  enlarged  and  movable  kidney.  In  a  case 
diagnosed  as  ovarian  tumour,  the  doubt  as  to  diagnosis  was  solved  by 
aspiration  of  an  enormous  quantity  of  purulent  fluid,  the  result  evidently  of  a 
pyo-nephritic  abscess.  The  great  size  to  which  renal  tumours  may  grow 
explains  the  occasional  inexcusable  error  of  mistaking  such  gi-owths  for 
ovarian  or  uterine  ones,  and  it  must  not  be  forgotten  that  renal  and  pelvic 
neoplasms  may  co-exist  in  the  same  patient. 

In  dealing  with  the  conditions  most  nearly  touching  the  province  of  the 
gynascologist,  Knowsley  Thornton  makes  these  verj^  pertinent  remarks 
regarding  hydro-nephrosis  and  renal  tumours  : — 

Hydro-Nephrosis :  Differentiation  from  Ovarian  Cystoma  and 
other  Cysts. 

'  This  is  not  always  easy  ;  retro-peritoneal,  omental,  and  mesenteric  cysts 
are  especially  difficult  to  differentiate  from  hydro-nephrosis,  and  it  has  been 
a  common  error  to  mistake  an  ovarian  cyst  for  hydro-nephrosis,  or  vice  versa. 
It  is  also  in  some  cases  difficult  to  distinguish  between  hydro-  and  pyo- 
nephrosis. The  position  of  the  colon,  curving  across  the  tumour,  is  one  of 
the  best  diagnostic  points  in  renal  tumours,  giving  a  clear  note  on  percussion 
over  their  inner  border.  Sometimes  this  is  lost  through  the  intestine  being 
contracted  and  empty,  but  even  then  it  can  often  be  defined  as  a  raised  cord, 
which  varies  in  shape  under  pressure.  In  very  large  tumours  the  bowel 
sometimes  gets  behind,  and  this  sign  is  altogether  lost.  I  have  seen  some 
retro-peritoneal  cysts  which  it  was  quite  impossible  to  distinguish  from 
hydro-nephrosis  till  the  abdomen  was  opened,  and'  in  one  case  I  did  not  dis- 
cover what  the  tumour  was  till  I  had  enucleated  a  considerable  portion  of 

*  See  chapter  on  the  Ureters. 


AFFECTIONS   OF   THE    KfDNFV.  053 

il.,  so  exactly  did  it  siinnlato  a  distended  adlierent  kidney.  There  should, 
however,  be  no  difficulty  in  dilTeretitiating  a  hydro-nephrosis  from  an  ovarian 
cyst,  and  yet  they  are  frequently  mistaken  for  one  another.  In  the  former 
there  is  the  position  of  the  colon,  the  dulness  going  far  back  into  the  loin 
and  under  the  ribs,  and  nearly  always  a  clear  line  between  the  lower  edge  of 
the  tumour  and  the  iliac  crest.  In  the  ovarian  cj'^st  the  dulness  and  fluctua- 
ticu  rarely  go  so  high  and  so  far  back,  and  though  its  upper  margin  is  often 
overlaid  bj''  clear  intestine,  there  is  not  the  same  fixed  curve  of  clear  note, 
and  the  dulness  extends  down  to  the  iliac  crest  and  pubes.  The  ovarian 
cyst  has  usuall}"  more  lateral  mobility  than  the  renal  cyst.  The  pelvic 
examination  alone  will  usually  distinguish  the  one  disease  from  the  other. 
The  hydro-nephrosis  rarely  becomes  pelvic ;  the  ovarian  tumour  is  nearly 
always  more  or  less  so.  If  the  lower  part  of  the  hydro-nephrosis  should 
enter  the  pelvis,  its  close  connection  with  the  bladder  can  be  traced,  while 
pressing  up  its  abdominal  portion  does  not  affect  the  uterus,  the  exact  reverse 
being  the  case  for  the  ovarian  cyst.  Careful  aseptic  puncture  far  back  in  the 
loin,  and  examination  of  the  fluid  removed,  are,  however,  in  many  cases,  the 
only  certain  means  of  diagnosis.' 

Angioma  of  the  Liver  simulating"  Movable  Kidney. 

A  young  married  woman,  aged  28,  was  sent  to  me  suffering  from  retroversion 
of  the  uterus  and  an  abdominal  tumour  occupying  the  right  hypochondrium 
and  lumbar  region.  The  tumour  was  freely  movable,  and  could  be  apparently 
isolated  from  the  liver.  Under  anaesthesia,  it  was  most  difficult  to  say  whether 
it  was  a  tumour  of  the  liver  or  an  enlarged  and  mobile  right  kidney.  Determin- 
ing, however,  that  it  was  a  tumour  of  the  liver,  I  opened  the  abdomen  with  a 
Langenbuch's  incision,  coming  down  on  a  large  bossy  tumour  about  the  size  of 
a  small  cocoanut,  gTOwingfrom  the  under  surface  of  the  right  lobe,  the  margin 
of  which  projected  over  part  of  it,  and  pushing  the  gall  bladder  towards  the 
left.  B}^  passing,  with  Deschamp's  needles,  strong  ligatures  through  its  base 
so  as  to  isolate  it,  and  then  ligaturing  the  tumour  in  sections  as  it  was  divided, 
finalh'  clamping  the  pedicle  until  it  was  completely  secured,  I  removed  it 
with  comparatively  little  loss  of  blood,  packing  the  pedicle  above  and  below 
with  iodoform  gauze.  The  patient  had  suffered  a  good  deal  from  the  time 
the  tumour  was  first  discovered  eighteen  months  previously,  and  was  conse- 
quently in  a  very  low  state  of  health.  She  suffered  considerably  from  shock, 
and  though  she  rallied  a  few  times  from  the  collapse,  she  never  quite  recovered, 
and,  notwithstanding  repeated  use  of  artificial  serum,  strychnine  subcutane- 
ously,  and  stimulating  enemata,  she  survived  only  twenty-two  hours  from  the 
completion  of  the  operation. 

Report  by  J.  H.  Targett  :— 

'  The  specimen  consists  of  a  lobulated  tumour,  somewhat  cubical  in  shape, 
and  measures  3^  ins.  x  3  ins.  x  2^  ins.  It  is  situated  in  the  free  margin  of 
the  liver  immediately  to  the  right  of  the  gall-bladder,  and  projects  more  on 
the  deep  than  the  convex  surface  of  the  liver.  Superiorly  the  specimen 
shows  some  deep  fissures  from  lateral  pressure,  and  the  yellow  hepatic  sub- 
stance is  mottled  with  extensive  areas  of  dark  brown  srrowth.     Inferiorlv  the 


954  DISEASES   OF    WOMEN. 


tumour  has  a  coarsely  nodular  outline,  and  the  surface  is  similarly  mottled 
with  yellow  and  dark  brown  patches.  On  section  the  tumour  has  a  spongy 
structure  ;  its  outline  is  distinct  in  consequence  of  its  colour,  and  areas  of  un- 
absorbed  hepatic  tissue  are  visible  at  the  periphery  of  the  neoplasm.  Histo- 
logically the  growth  is  an  angioma  of  the  liver,  and  there  is  no  evidence  of 
malignant  disease  in  it.  Its  structure  consists  of  irregular  spaces  lined  with 
endothelium,  and  separated  by  strands  of  soft  nucleated  fibrous  tissue,  in 
which  no  traces  of  unstriped  muscle  can  be  found.  Some  of  the  larger  spaces 
contain  thrombi  in  process  of  organization.  The  older  parts  of  the  fibrous 
stroma  are  becoming  hyaline  and  denucleated,  while  in  the  advancing  margin 
the  capillary  vessels  are  very  numerous,  and  the  stroma  is  scanty.' 

Cholecystotomy  for  Empyema  of  the  Gall-bladder  after  Typhoid 
Fever,  complicating  Movable  Kidney. 

Some  time  since  I  performed  cholecystotomy  under  the  following  circum- 
stances :  A  lady  had  been  attacked  with  tjqihoid  fever  in  India,  and 
recovered  under  the  care  of  Professor  Havelock  Charles,  after  violent 
haemorrhage  and  undoubted  perforation  of  the  bowel.  She  suffered  from 
periodical  attacks  of  most  violent  abdominal  pain,  principally  at  the  right 
side.  Various  opinions  were  given  as  to  its  source,  some  considering  the 
attacks  to  be  due  to  peritoneal  stretching  from  adhesions,  others  to  locaHzed 
peritonitis,  while  others  thought  that  there  was  evidence  of  gall-stones. 
Unfortunately  for  the  patient,  her  symptoms  were  also  attributed  to  neuras- 
thenia and  neurosis.  Every  form  of  sedative  failed  to  relieve  her,  she  could 
neither  eat  nor  sleep,  and  became  greatly  emaciated.  When  I  first  saw  her 
she  had  practically  taken  nothing  but  water  for  several  days.  An  expe- 
rienced anaesthetist  administered  chloroform  for  purposes  of  diagnosis,  and 
she  had  a  narrow  escape  from  its  effects.  I  found  no  evidence  of  any  disease 
in  her  pelvic  organs  ;  there  was  a  loose  kidney,  somewhat  enlarged,  and  I 
could  detect  some  resistance  with  hardness  in  the  region  of  the  gall-bladder. 
Before  any  operative  measures  were  carried  out,  inasmuch  as  these  would  at 
that  time  certainly  have  proved  fatal,  I  advised  that  she  should  have  a  period 
of  prolonged  rest.  At  the  end  of  six  weeks,  under  a  Weir-Mitchell  course  of 
treatment,  she  had  put  on  flesh,  the  kidney  was  much  less  movable,  and  the 
attacks  of  pain  had  nearly  disappeared.  -  They  recurred  suddenly  with  great 
violence,  accompanied  by  sickness,  and  were  exactly  of  the  same  nature  as 
those  from  which  she  had  suffered  before  I  saw  her.  I  again  ansesthetized 
.  her,  and  as  it  was  evident  that  the  symptoms  could  not  be  due  to  the  kidney 
alone,  I  resolved  to  explore  the  abdomen  by  a  Langenbuch's  incision,  dealing 
with  the  kidney  if  necessary,  and  at  the  same  time  examining  the  gall- 
bladder. I  found  the  latter  surrounded  by  adhesions,  greatly  thickened,  con- 
taining pus,  and  with  a  widely  dilated  duct;  in  short,  a  typical  case  of 
empyema.  The  duct  was  carefully  explored  through  the  bowel,  the  gall- 
bladder thoroughly  cleansed  and  wiped  out  with  a  1  in  1000  of  formalin,  the 
walls  attached  to  the  peritoneum,  and  both  to  the  parietes,  an  iodoform  gauze 
drain  being  used.  The  patient  made  a  perfect  recovery  from  the  operation, 
but  there  remained  a  small  fistulous  canal  through  which  mucus  escaped.   As 


PLATE   CXXI. 


AXGIOMA   OF   THE    LiVER   GROWING   FROJI    THE    UxDER    SURFACE    OF   THE    RiGHT   LOBE. 

Simulating  a  movable  kidney  (see  also  pp.  44,  45).     Eemoved  by  Author.     (Xat.  size.) 

(Vide -p.  9oy>.) 

[To  face  p.  954:. 


PLATE   CXXII. 


^•.A-^w*' 


0  c- 0  U:;:'^^\ 


'?.;.  Y/;-w,y 


Fig.  a.     X  70. 
A,  uormal  liver  cells  ;  B,  vascular  spaces  ;  C.  a  portion  shown  in  Fig.  B. 


Fig.  B.     X  300. 

Showing  the  vascular  space,  with  the  endothelium  and  blood  discs  (portion 

of  C  iu  Fig.  A). 

Sections  op  Angioma  of  the  Liver. 

IToface'p.  955. 


AFFECTIONS   OF    THE   KTDNEY.  055 

she  was  compelled  to  leave  England  before  she  was  fit  for  a  second  opera- 
tion, I  consented  to  her  doing  so.  The  fistulous  opening  has  since  been 
successfully  closed,  a  small  concretion  being  found  at  the  bottom  of  a  fistulous 
track. 


Renal  Tumours — Diagnosis. 

'  The  tumours  most  likely  to  be  mistaken  for  renal  tumours  are :  (1)  Re- 
tro-peritoneal cysts ;  often  quite  impossible  to  diagnose  from  hydro-nephrosis. 
(2)  Omental  cysts ;  easier  on  account  of  the  different  relations  of  the  bowel. 
On  the  right  side  (3)  Distended  gall-hJadder,  when  surrounded  by  adhesions, 
quite  impossible  to  differentiate  in  some  cases  from  renal  tumour ;  when  free 
and  mobile,  its  exact  relations  are  easier  to  define.  (4)  Enlurfjement  of  the 
spleen ;  this  ought  not  to  be  mistaken  for  renal  tumour  :  first,  there  is  the 
notch,  always  to  be  found  with  careful  search ;  then  there  is  the  hard,  sharp 
border,  quite  different  from  any  renal  tumour ;  then  the  percussion  is  dull 
to  the  very  edge  of  the  tumour ;  the  intestine  never  overlaps  unless  it  is 
adherent,  which  is  very  rare.  (5)  Ovarian  tumour.  A  suh-pieritoneal  fihro- 
myoma  uteri  might  be  very  difficult  to  differentiate  from  a  renal  tumour,  if  the 
latter  were  large  enough  to  dip  into  the  pelvis.' 

Temporary  Disappearance  of  the  Renal  Swelling. — There  is  one 
point  of  importance  in  regard  to  certain  enlargements  of  the  kidney 
not  to  be  forgotten,  and  which  may  both  puzzle  the  practitioner  and 
reflect  unpleasantly  on  his  opinion,  viz.  the  chance  of  a  temporary 
subsidence  or  disajjpearance  of  the  tumour.  This  may  happen  in  the 
case  of  hydro-nephrosis  or  pyo-nephrosis,  when  the  fluid,  which  has 
been  imprisoned  by  some  obstruction — as,  for  instance,  a  calculus  in 
the  ureter — passes  into  the  bladder  through  removal  of  the  impedi- 
ment, and  a  previously  blocked  ureter  becomes  pervious  ;  or  it  may 
occur  in  the  instance  of  a  movable  kidney,  the  shifting  or  displace- 
ment of  which  may  depend  on  posture  or  occupation. 

Movable  or  Displaced  Kidney. — The  only  afl:ection  of  the  kidney 
that  I  propose  to  deal  with  in  any  detail  is  that  of  movable  kidney. 

Etiology. — A  distinction  has  been  drawn  (Jenner)  between 
'movable'  kidney  and  'floating'  kidney,  the  latter  term  being 
applied  to  that  form  of  displacement  in  which  there  is  a  meso- 
nephron  or  fold  of  peritoneum  attaching  it  to  the  vertebral  column . 
This  is  by  far  the  rarer  variety  of  displacement.  It  is  at  times  a 
congenital  malformation.  Displaced  kidney  may  follow  from  shock, 
falls,  blows,  or  other  injury.  The  displacement  may  be  caused  by 
pelvic  or  abdominal  growths  ;  as  uterine  myomata  and  ovarian 
cystoma. 

The  inexperienced  practitioner  may  be  excused  for  overlooking 


956  DISEASES   OF    WOMEN. 

an  affection  of  which  the  symptoms  in  the  milder  forms  of  displace- 
ment are  often  obscure.  The  fact,  however,  that  movable  or  float- 
ing kidney  is  found  much  more  frequently  in  women  than  in  men 
(in  the  proportion  of  seven  to  one),  and  that  it  is  still  commoner  in 
those  women  who  have  borne  children  than  in  the  unmarried  (in 
consequence,  probably,  of  the  greater  laxity  of  the  abdominal  wall 
in  the  former  class),  invests  this  renal  affection  with  special  interest 
in  the  eyes  of  the  gynaecologist.  Any  prolonged  or  exhaustive  drain 
on  the  system,  which  weakens  the  abdominal  parietes  and  causes 
absorption  of  the  circumrenal  fat,  is  apt  to  predispose  to  loosening 
of  the  kidney. 

'  Women,'  says  Greig  Smith,  '  with  long  flexible  spines  and  sloping 
lower  ribs,  which  do  not  rise  well  forwards,  but  lie  closely  over  or 
in  contact  with  the  kidney,  provide  the  most  abundant  examples  of 
this  condition.' 

I  have  frequently  found  movable  kidney  in  women  who  have  suffered  from 
severe  haemorrhage  from  hsemori-hoids,  after  pregnancy,  and  in  cases  of 
malignant  disease. 

Movable  Kidney  and  Appendicitis. — Renal  displacement  is  seldom 
met  with  in  very  young  patients.  The  right  kidney  is  generally 
the  one  most  frequently  found  mobile.  Hypertrophy  of  the  kidney 
or  a  renal  tumour  may  be  the  cause  of  the  mobility.  A  patient 
who  suffered  for  some  years  fi'om  a  pyo-nephritis  consulted  me.  I 
found  the  left  kidney  so  reduced  in  size  that  it  was  impossible  to 
prove  its  presence.  The  right  kidney  was  greatly  hyper trophied, 
and  freely  movable. 

Edebohls  *  draws  attention  to  the  special  relations  of  movable  kidney  to 
chronic  appendicitis.  He  says  that  the  latter  may  be  the  only  symptom  of 
movable  right  kidne3\  The  appendicitis  is  the  result  of  the  renal  condition, 
and  this  he  attributes  to  indirect  pressure  of  the  superior  mesenteric  vein, 
hampering  the  return  circulation  of  the-appeudix  by  compression  of  the  vein 
between  the  liead  of  the  pancreas  and  the  spinal  column.  The  majority  of 
patients  require  both  nephrorrhaphy  and  appendicectomy  to  restore  them  to 
full  health,  and  both  operations  can  be  performed  simultaneously  by  extending 
the  lumbar  incision  along  the  outer  margin  of  the  erector  spinee  muscle  to 
the  crest  of  the  ilium.  In  regard  to  its  relations  to  diseases  of  the  female 
pelvic  organs,  Edebohls  views  the  general  relaxation,  which  starts  at  the 
lamina  fibrosa  of  the  renal  adipose  capsule,  as  present  also  in  the  supports 
of  the  uterus,  leading  to  its  retroversion  and  prolapse.  He  strongly  empha- 
sizes the  great  importance  of  early  diagnosis  of  the  renal  condition,  in  order 
to  avoid  the  unpleasant  consequences  which  must  follow  from  the  failure  of 

*  Med.  Bee.,  Marxjh  11,  1899. 


AFl'ECriONS   OF   THE  KTDNET.  957 

a  pelvic  operation  to  give  relict'  if  the  mobility  of  the  kidney  be  not  rectified 
either  before  or  after  the  pelvic  kidney  affection  has  been  cured.  Another 
important  point  noticed  by  Edebohls  is,  that  a  pregnant  uterus  or  a  myoma- 
tous tumour  forms  splints  for  the  support  of  the  loose  kidney,  and,  as  a  con- 
sequence, after  labour  or  the  removal  of  an  ovarian  or  myomatous  tumour, 
recurrence  of  the  symptoms  due  to  the  movable  kidney  is  to  be  expected. 
With  regard  to  appendicitis  as  a  complication  of  pelvic  disorders  in  women, 
so  frequently  docs  this  occur  that  he  lays  down  the  rule,  which  has  been 
equally  insisted  upon  by  Howard  Kelly  and  others,  that  the  abdomen  should 
never  be  opened  anywhere  within  a  finger's  length  of  the  appendix  without 
investigation  of  the  condition  of  the  latter.  If  it  be  found  diseased  it  should 
be  ablated,  even  if  it  be  necessary  to  remove  the  incision  for  this  purpose, 
while,  if  normal,  it  should  be  inverted  entire,  if  possible  without  enlarging 
the  incision. 

Edebohls  does  not  regard  chronic  nephritis  as  a  contra-indication  to  the 
operation  of  nephrorrhaphy  ;  on  the  contrary,  he  advises  the  operation  as  a 
remedial  step  for  this  affection,  and  instances  cases  in  support  of  this  view, 

Walter  Man  ton,*  in  referring  to  Edebohls'  contention  with  regard 
to  movable  kidney  and  appendicitis,  takes  the  record  of  200 
selected  in  succession  from  his  cases,  and  shows  that  36^  per  cent. 
suBTered  from  mobility  of  the  right  kidney,  and,  of  this  latter  number, 
in  65 5"  per  cent.,  chronic  appendicitis  was  diagnosed,  of  which  22^ 
per  cent,  were  operated  upon  and  the  diagnosis  confirmed.  He 
specially  emphasizes  the  rules  already  laid  down  by  Edebohls,  viz. 
(1)  With  obscure  abdominal  conditions,  even  when  no  pelvic  dis- 
order is  discoverable,  a  diagnosis  should  not  be  attempted  until 
movable  kidney  and  appendicular  disease  can  be  excluded  by  careful 
abdominal  palpation.  (2)  When  nephroptosis  and  appendicitis  are 
present,  operations  upon  the  uterus  and  adnexa  alone  will  not  be 
followed  by  cure  of  the  patient  unless  one  or  both  of  these  conditions 
have  also  been  removed. 

Diagnosis. — I  have  already  described  the  method  of  examining 
for  a  movable  or  displaced  kidney.  We  have  to  differentiate  dis- 
placed kidney  from  a  tumour  of  the  pancreas,  liver,  gall-bladder, 
pylorus,  and  omentum,  a  fsecal  tumour  of  the  colon,  ovarian  cystoma, 
extra-ovarian  cysts,  hydro-salpinx,  and  pyo-salpinx.  In  any  case 
of  doubt,  therefore,  careful  examination  of  the  abdominal  and 
pelvic  viscera  should  be  made  before  a  conclusion  is  arrived  at. 
The  tumour  gives  a  characteristic  mobile  sensation  to  the  hands, 
the  kidney  with  bimanual  pressure  slipping  from  between  them. 
Manipulation  is  sometimes  attended  with  pain,  and  this  may  last 
for  some  time  after  the  examination  is  over. 


*  Amer.  Gyn.,  Jan,  V3(YA. 


958  DISEASES  OF   WOMEN. 

In  women  with  lax  parietes  and  general  looseness  of  the  abdominal  organs, 
or  in  those  in  whom  the  parietes  are  very  resisting,  a  distended  gall-bladder 
may  easily  be  mistaken  for  a  mobile  kidnej'.  The  two  conditions  may  also 
co-exist.  Greig  Smith,  referring  to  the  oblique  direction  of  the  growth  of  the 
gall-bladder  tumour,  points  out  that  the  tumour  has  grown  before  we  have 
seen  it,  and  is  '  too  small  to  have  any  definite  direction.' 

The  superficial  position  of  the  gall-bladder  will  not  help  us  if  the 
intestines,  in  palpation,  rise  above  it,  and  in  the  case  of  a  very 
mobile  kidney,  in  a  thin  woman,  the  kidney  appears  to  be  directly 
under  the  hand  when  she  is  turned  on  her  side.  However,  it  may 
be  safely  said  that  such  cases  of  difficult  diagnosis  are  very  rare, 
and  that  the  detection  of  a  movable  kidney _,  in  the  great  majority 
of  cases,  is  comparatively  easy.  In  those  exceptional  cases,  only  by 
careful  percussion  and  palpation  in  different  positions  is  a  decision 
to  be  arrived  at.  Other  sources  of  error  must  be  avoided  by  atten- 
tion to  the  particular  symptoms  likely  to  accompany  them.  The 
gastric  disturbances  will  warn  us  not  to  overlook  the  possibility  of 
a  pyloric  growth,  which,  as  Greig  Smith  points  out,  glides  from 
under  the  palpating  fingers  directly  upwards,  and  not  upwards  and 
backwards,  as  in  the  case  of  the  kidney.  The  situation,  however, 
of  the  pyloric  tumour,  and  its  fixed  position,  are  quite  distinctive 
features  in  this  case.  The  sensations  of  faintness  and  sickness 
frequently  complained  of  in  handling  a  floating  kidney  are  also  helps 
in  arriving  at  a  conclusion. 

Symptomatology. — Both  the  signs  and  symptoms  of  renal  dis- 
placement will  depend  upon  its  degree,  and  whether  one  or  both 
organs  are  mobile.  Those  attending  slight  displacement  are  fre- 
quently so  mild  in  character  that  they  may  not  arouse  the  suspicion 
of  the  surgeon  as  to  the  real  cause  of  the  temporary  pain  or 
distress,  which  is  only  periodically  complained  of.  I  have  frequently 
seen  cases  with  single  or  double  movable  kidney  in  which  the  dis- 
covery has  been  accidentally  made  in  an  abdominal  examination, 
called  for  by  symptoms  of  a  pelvic  aff"ection  or  gastric  disturbance, 
where  there  was  no  suspicion  of  any  abdominal  tumour.  Some 
of  these  patients  sought  advice  for  aggravated  dyspepsia  and 
gastrodynia  or  other  reflex  pains.  If  a  woman  complains  of  a 
constant  or  recurring  pain  in  the  lumbar  region,  occasionally 
extending  up  the  side  or  downwards  to  the  groin,  or  which  is 
increased  by  exercise,  and  in  all  cases  where  there  is  a  history  of 
obscure  gastric  trouble,  we  must  carefully  exclude  movable  kidney 
as  a  possible  source  of  the  symptoms. 


AFPliCriONS  OF  THE  KIDNEY. 


959 


There  may  be  occasional  attacks  of  syncope  caused  by  pain,  which 
varies  with  the  degree  of  mobility  and  the  size  of  the  kidney. 
After  a  time  the  organ  may  be,  and  frequently  is,  enlarged.  Hydro- 
nephrosis or  pyo-nephrosis  may  be  present.  The  tumour  then  may 
fill  the  space  between  the  crest  of  the  ilium  and  the  last  rib,  and 
much  of  the  previous  mobility  may  disappear.  In  cases  in  which 
the  displacement  has  lasted  for  some  time  the  general  health  suffers 
more  or  less.  There  is  frequently  sickness  or  nausea.  The  patient 
becomes  nervous,  and  loses  flesh  more  raj)idly ;  the  pain  is  more 
constant,  constipation  is  frequently  present,  as  are  the  other  natural 
results  of  want  of  exercise  and  loss  of  appetite. 

A  young  girl  was  sent  to  me  who  bad  been  twice  in  hospital  with  symptoms 
of  gastric  ulcer.  Each  time  sbe  became  somewhat  better  for  the  treatment, 
but  after  a  while  the  trouble  recurred,  and  when  I  saw  her  it  was  a  question 
of  having  to  give  up  her  employment  from  the  constant  pain  and  nausea. 
She  was  also  greatly  reduced  in  weight.  On  examination  I  found  a  large 
and  very  mobile  right  kidney.  Nephrorrhaphy  was  performed,  and  since  her 
recovery  from  the  operation,  which  was  rapid,  she  has  liad  no  return  of  the 
symptoms,  and  is  quite  restored  to  health. 

Treatment. — Outside  the  general  indications  for  the  consti- 
tutional conditions  that  complicate  a  mobile  kidney,  the  special 
treatment  resolves  itself  into  the 
use  of  a  well-made  support  or  the 
operation  of  nephrorrhaphy.  The 
operation  of  nephrectomy  is  not  to 
be  named  by  any  surgeon  in  discuss- 
ing simple,  uncomplicated  movable 
kidney.  I  have  made  many  women 
fairly  comfortable,  though  both  kid- 
neys were  mobile,  who  were  able  to 
go  about  their  household  and  other 
duties  wearing  a  kidney-belt  with 
double  supports.  The  form  I  prefer 
is  that  shown  (Fig.  606).  A  light 
steel  plate  is  incorporated  with  the 
web  lining  ;  this  is  well  padded,  or  can  be  coA'ered  with  an  air-pad. 
The  plate  is  sufficiently  large  to  cover  comfortably  the  renal  region. 
In  the  front  of  the  belt  is  another  air-pad,  with  a  stop-cock 
attached,  so  that  the  size  of  the  pad  can  be  increased  or  diminished 
at  pleasure.  I  find  this  double  support,  behind  and  in  front, 
far   preferable    to    the    belt    ordinarily    sold,    with    the    pad    only 


Fig.  606.  —  Ax;thou's  Belt  for 
Movable  Kidney,  with  India- 
RUBB3R  Inflating  Dorsal  Pad, 
Leather  Convex  Back  Pad,  and 
Indiauubbeu  Understkaps. 


960  DISEASES  OF   WOMEN. 


behind.  I  also  think  that  the  curved  plate  of  steel,  about  the 
width  of  the  palm  of  the  hand,  is  more  resisting  and  efficient  than 
the  air-pad  posteriorly.  I  always  see  that  the  size  and  position  of 
the  front  and  back  pads  are  made  in  accordance  with  the  indications 
of  each  individual  case.  Should  such  support  fail  to  give  relief,  and 
the  patient  be  willing  to  undergo  nephrorrhaphy,  the  operation 
should  be  performed.  The  steps  of  this  operation  are  briefly  the 
following  : — 

Nephrorrhaphy. 

The  patient  having  been  laid  in  the  proper  position,  with  a  small 
and  hard  pillow  under  the  loin,  an  oblique  incision  to  expose  the 
kidney  is  carried  from  the  outer  border  of  the  erector  spinse,  half 
an  inch  below  the  last  rib,  towards  the  crest  of  the  ileum,  for  the 
extent  of  three  inches ;  the  length  of  the  incision  must,  however, 
depend  upon  circumstances.  This  incision  divides  the  skin,  fat,  and 
fascia,  and  exposes  the  outer  edge  of  the  latissimus  dorsi  and  the 
posterior  border  of  the  external  oblique  muscle.  The  deeper  part 
of  this  incision  should  correspond  in  extent  with  the  skin  wound. 
When  the  aponeurosis  of  the  internal  oblique  and  transversalis  has 
been  sufficiently  divided,  the  quadratus  lumborum  muscle  is  exposed 
and  retracted,  and,  lastly,  the  lumbar  fascia  is  incised  to  the  extent 
of  the  entire  wound.  Forcipressure  is  used  for  the  control  of  bleed- 
ing vessels.  The  perirenal  fat  and  fascia  having  been  well  exposed 
by  retractors,  the  former,  save  in  rare  cases  when  it  is  closely  adherent 
to  the  capsule  of  the  kidney,  is  opened,  and  the  viscus  is  exposed. 
The  aseptic  linger  is  then  freely  used  to  determine  the  degree  of 
mobility,  and  to  excite  plastic  adhesions.  The  next  step  consists  in 
thoroughly  freeing  the  kidney  of  its  fatty  tissue,  so  as  to  bring 
it  to  lie  on  the  muscular  structure.  The  capsule  is  now  scratched 
with  the  finger-nail.  The  kidney,  thus  completely  freed,  is  drawn 
into  the  abdominal  wound.  Buried  sutures  are  passed,  three  in 
number,  through  the  substance  of  the  kidney,  an  inch  from  its  free 
margin.  These  sutures  are  carried  through  the  muscle  and  apo- 
neurosis, and  are  temporarily  thrown  aside.  The  wound  is  now 
carefully  swabbed  with  moist  formalin  dabs,  and  then  dried 
thoroughly  with  sterilized  gauze.  The  fatty  tissue,  where  rent, 
is  sewn  up  with  fine  cumol  gut;  then  the  divided  aponeurosis  is 
united,  and  the  renal  sutures  are  tied.  The  wound  is  finally 
mopped  with  formalin,  and  the  edges  of  the  skin  are  united  with 


AFFECTIONS   OF   THE   KfDXEV.  fi61 

celloidinzwirn.    The  entire  operation,  from  first  to  last,  is  aseptically 
conducted. 

Puncture  of  the  Kidney. — In  cases  where  we  are  in  doubt  as 
regards  the  nature  of  a  renal  swelling,  or  the  character  of  the 
contained  fluid,  aspiration  is  the  proper  preliminary  step  to  take. 

'  An  abundant  experience  of  tiiis  very  simple  operation,'  says  Greig  Smith, 
'  proves  that  it  is  too  frequently  allied  to  the  experiment  of  introducing  a 
germ-laden  needle  into  the  midst  of  a  cultivation  jelly.'  Thus  he  accentuates 
the  care  which  ought  to  be  taken  to  ascepticize  the  needle-point  and  fill  the 
puncturing-needle  of  the  aspirator  with  some  antiseptic  fluid  in  making  the 
puncture. 

In  gynaecological  practice — to  which  alone  I  refer — this  step  is 
undertaken  both  as  a  means  of  diagnosis  and  as  a  therapeutic 
measure,  in  order  to  draw  off  the  fluid.  Morris  recommends  as  the 
point  of  entrance  of  the  needle  on  the  left  side,  ^ just  anterior  to  the 
last  intercostal  space  ; '  and  on  the  right  side,  '  a  point  half  way  between 
the  last  rib  and  the  crest  of  the  ilium,  from  two  to  two  and  a  half  inches 
behind  the  anterior  superior  spine  of  the  ilium.' 

Though  a  needle  passed  horizontally  inwards  at  this  point  is  '  altogether  in 
front  of  the  normal  kidney,  and  will  either  transfix  or  pass  in  front  of  the 
ascending  colon  when  in  its  usual  place,'  Morris  points  out  that  in  enlarge- 
ment of  the  kidney  of  the  right  side  in  cases  of  hydro-nephrosis,  if  the  needle 
be  directed  somewhat  forwards  both  peritoneum  and  colon  wih  escape,  and 
the  pelvis  of  the  kidney  wiU  be  tapped  at  its  anterior  and  lower  aspect. 

The  needle  is  directed  sufficiently  forwards  to  escape  the  kidney, 
but  not  so  far  as  to  endanger  the  colon  and  peritoneum.  The 
greatest  care  must  be  taken  when  the  fluid  is  escaping,  and  the 
cavity  is  nearly  empty,  not  to  push  the  needle  farther  in,  so  as 
to  avoid  the  risk  of  wounding  either  the  renal  vessels  or  the 
peritoneum. 

This  operation,  we  must  remember,  is  both  curative  and 
diagnostic.  Its  performance  will  often  save  the  necessity  for  a 
nephrotomy,  or  possibly  a  nephrectomy,  and  is  always  indicated  in 
the  case  of  simpjle  cysts,  hydro-nephrosis,  and  hydatid  cyst.* 

Renal  Calculus. — The  subject  of  renal  calculus  is  here  referred 
to  in  order  to  draw  attention  to  the  obscure  symptoms  which 
frequently  accompany  the  presence  of  a  concretion  in  the  kidney. 
In  all  cases  where  there  is  frequent  micturition,  with  associated 
pain  in  the  lumbar  region,  extending  to  the  groin,  a  careful  exami- 
nation   of   the   urine    should   be    made.     The    kidneys    should    be 

*  See  Greig  Smith's  '  Abdominal  Sureerv.'  6th  ed.,  vol.  ii. 

3   Q 


962 


DISEASES   OF    WOMEN. 


palpated  and  the  ureters  explored,  at  the  same  time  that  such  causes 
of  urinary  distress  and  disturbance  as  uterine  displacements,  pelvic 
tumours,  and  adnexal  disorders  are  excluded.  Still,  in  some  cases 
nothing  save  renal  exploration  will  clear  up  the  doubt. 

As  bearing  on  the  uncertainty  of  symptoms,  even  in  a  large 
calculus  of  the  kidney,  the  following  case  of  Spanton  (Hanley)  is 
of  interest : — 


Renal  Calculus. 

The  symptoms  were  fairly  characteristic  of  stone  in  the  kidney,  leading  up 
to  pyo-nephritis.     The  patient,  who  had  had  eight  children,  '  twelve  months 

ago  first  felt  pain,  but 
thought  it  was  indigestion. 
Two  years  since  she  over- 
walked  herself,  and  on  re- 
turning passed  urine  of  a 
dark  purplish  colour,  but 
the  urine  was  natural  after- 
wards. 

'  About  two  months 
since  first  noticed  small 
swelling  in  right  iliac  re- 
gion ;  this  caused  more 
pain  than  patient  remem- 
bered having  before,  but 
even  this  was  not  severe ; 
no  pain  on  micturition. 
Passed  urine  about  eight 
times  in  twenty-four  hours. 
The  urine  had  had  a  thick 
sediment  in  it  for  the 
previous  twelve  months. 
Twenty  ounces  of  pus 
were  passed  in  the  twenty- 
four  hours.' 

During  operation  several 
ounces  of  foetid  pus  and 
urine  were  drawn  from  the 
kidney.     The  patient  was 
operated  upon  twice  before  the  entire  calculus  could  be  removed. 

An  interesting  feature  of  the  case  was  the  comparatively  slight  local  trouble 
present,  nor  was  there  any  history  of  renal  colic.  There  was,  however, 
considerable  wasting,  with  great  weakness.  The  patient  made  a  complete 
recovery. 

Noble  has  reported  a  case  exemplifying  the  bad  results  which  follow  from 
neglected  calculus  in  the  kidney.     It  also  demonstrates  how  an  irritable 


Fig. 


607. — Phosphatic  Calculus  removed  from 
Eight  Kidney.     (W.  Spanton.) 

Weight  980  trains.     Exact  size. 


AFFECTIONS  OF  THE  KIDNEY. 


963 


Fig.  608. — Branched  Calculus  fobmixg  a  Cast  of  the  Pelvis  antd 
Calyces  of  the  Kidney.    (P.  J.  Feeyeb.) 

Kemoved  from  a  female,  aged  34.  Weight,  514  grains.  Composed  of  urates 
and  phosphates,  the  latter  largely  predominating.  Drawing  shows  the 
exact  size.  Though  the  kidney  was  much  disorganized,  it  was  left 
behind.     The  patient  made  a  rapid  and  complete  recovery  in  a  month. 


Fig.  009. — Degeneration  of  the  Kidney,  the  Kesult  of  Pyelo-nephritis, 
consequent  upon  an  Impacted  Ureteral  Calculus.  (C.  Noble.) 
(Pages  962-964.) 


964  DISEASES   OF    WOMEN. 

bladder  may  be  tbe  principal  symptom  in  such  a  case,  as  also  the  value  of 
catheterization  of  the  ureters  as  a  diagnostic  step.  Pus  was  drawn  from  both 
kidneys,  the  urine  from  the  right  containing  also  albumen  and  blood.  That 
the  right  kidney,  though  not  normal  in  structiu-e,  was  doing  practically  all  the 
work  in  the  elimination  of  urine,  was  also  proved.  Nephrectomy  for  the 
removal  of  the  left  kidney  was  performed,  and  the  patient  made  a  good 
recovery.  The  degenerated  kidney  was  riddled  with  abscesses,  and  the 
source  of  the  trouble  was  found  to  be  a  calculus  impacted  in  the  upper  end  of 
the  ureter.  The  calculus  weighed  about  2  grs.,  and  was  about  half  an  inch 
in  length,  its  composition  being  oxalate  of  lime.  Noble  argues  that  such  a 
case  shows  the  urgent  necessity  for  early  instrumental  examination  by  the 
Rontgen  ray  cystoscopy  and  catheterization,  followed  by  nephrotomy. 


CHAPTER   XLVIII. 

SOME    AFFECTIONS    OF    THE    RECTUM. 

The  affections  of  the  rectum  in  women  which  the  practitioner  is 
called  on  to  diagnose  and  treat  are  : — 

Proctitis.  Malignant  disease  (continued) : 
Impaction  of  f feces.  Colloid. 

Fistula  and  abscess.  Melanosis. 

Hjemoi-rhoids,  external.  Syphilitic  disease  : 

„  internal.  Yarious    cutaneous    aflfections 

Simple  ulceration.  of  the  anus. 

Fissure.  Ulceration. 

Stricture.  Stricture. 

Malignant  disease  :  Pruritus  ani. 

Epithelioma.  Foreign  bodies  in  the  rectum. 

Scirrhus.  Procidentia. 

Encephaloid.  Polypus. 

The  anatomical  points  of  importance  which  have  a  special  bearing 
on  the  examination  of  the  rectum,  and  its  clinical  relationships  to 
the  other  pelvic  viscera,  were  referred  to  briefly  in  the  first  chapter 
of  this  work.  The  value  of  rectal  exploration  in  making  a  diagnosis, 
especially  in  children,  was  there  exemplified.* 

It  is  not  possible  to  deal  exhaustively,  in  a  manual  of  this  nature, 
with  the  treatment  of  the  various  diseases  of  the  rectum  here 
enumerated.  It  is  desirable  to  make  a  few  general  observations, 
however,  regarding  those  affections  which  we  have  most  frequently 
to  treat  in  women. 

Examination. — To  examine  the  patient  for  rectal  disease,  she  is 
placed  on  her  right  side  or  back,  with  the  knees  well  drawn  up.  An 
enema  should  be  previously  administered.  In  cases  in  which  thei'e 
is  excessive  sensitiveness,  or  where  a  thorough  exploration  is  re- 
quired to  diagnose  the  presence  and  extent  of  malignant  disease, 

*  See  also  chapter  on  Diseases  of  the  Fallopian  Tubes. 


966 


DISEASES   OF   WOMEN. 


painful  ulcer  or  fissure,  an  ansesthetic  should  be  given.     The  need 
for  examination  becomes  clear  when  there  are — 

A  sense    of   fulness   and    jDain    in    the   neighbourhood    of    the 

anus. 
Pain  during  and  after  defsecation. 
Prolapse  of  the  bowel. 
Haemorrhage. 
Discharge  of  any  kind. 

Without  an  anesthetic,  after  an  enema  is  administered,  the  patient 
can  be  made  to  expose  the  bowel  by  bearing  down,  and  thus  the 


Fig.  610. — Examination  of  the  Eectum  with  Proctoscope. 
(Howard  Kelly.) 

practitioner  can  reach  with  the  finger  to  a  higher  spot.  He  must 
trust  to  the  education  of  the  finger  in  examinations  of  the  rectum 
rather  than  to  the  assistance  gained  from  any  speculum.  He  should 
learn  to  recognize  by  touch  the  uneven  and  roughened  feeling  of  ulcera- 
tion, the  characteristic  hardness  of  malignant  disease,  the  smooth  hut  tense 
feeling  of  hsemorrhoids,  the  contraction  that  is  the  result  of  stricture,  the 
chinJc  of  a  fissure,  the  pedunculated  attachment  of  a  polypus,  and  the 


SOME  AFFECTIONS  OF  THE  RECTUM. 


907 


internal  aperture  of  a  fistula.  Above  all,  he  must  not  be  misled  by 
the  common  statement  of  a  patient  tliat  she  sufieis  from  '  l^leeding 
piles,'  and  be  satisfied  with  her  assurance  on  this  point,  even  though 
she  tells  him  that  she  has  been  under  treatment  for  piles.  It  is  not 
unusual  to  see  patients  who  never  suspected  there  was  anything 
more  serious  than  a  htvmorrhoidal  state  of  the  bowel,  yet,  on 
examination,  advanced  malignant  disease  is  discovered,  or  more 
frequently  a  fissure  or  ulcer.  The  dilatation  of  the  sphincter  is 
eftected  under  anaesthesia ;  and  when  this  is  done,  as  it  should  be 
slowly  and  without  using  force,  we  can,  with  a  suitable  speculum, 
completely  explore  the  rectum.*  Simon's  method  of  examination 
has  already  been  referred  to. 

Eversion  of  the  rectum  in  multiparas  may  be  secured  by  pressing 
on  the  tube,  with  the  fingers  carried  into  the  vagina  (Storer). 

We  may  adopt  the  same  method  of  examination  and  illumination 
of  the  rectum  as  in  the  case  of  the  bladder,  using  a  ^proctoscope 
and  forehead  illumination.  The  position  in  which  the  patient  is 
placed  is  the  same  as  when  examining  the  latter  viscus.  The 
accompanying  drawing  from  Kelly's  work  sufliciently  explains  this. 

Recto-Romanoscopy  (Kelen). — For  the  illustration  of  the  instru- 
ment shown  (Fig.   611)  I  am  indebted  to  Dr.  Stephen  Kelen,  of 


Fig.  611. — Proctoscope  of  Stkauss. 


Carlsbad.  It  is  a  proctoscope  constructed  by  Strauss,  which 
enables  the  sigmoid  to  be  examined.  It  consists  of  a  metal  tube 
'  30  cms.  long,  20  mms.  in  diameter.     The  interior  is  coated  black, 

*  See  p.  91. 


968  DISEASES   OF   WOMEN. 

the  exterior  is  nickel-plated,  well-polished,  and  has  a  centimetre 
scale.  One  end  of  the  tube  is  conically  enlarged,  and  carries 
a  handle  ;  immediately  behind  this  is  a  small  pipe  communicating 
with  the  tube,  on  which  is  mounted  the  opening  of  an  India-rubber 
tube  of  an  ordinary  insufflator.' 

The  examination  with  the  instrument  is  based  upon  the  same 
principles  as  those  of  Tuttle's  pneumatic  proctoscope,  viz.  the  infla- 
tion of  the  rectum  and  the  sigmoid  flexion  with  air. 

'  To  introduce  it,  the  tube  must  be  closed  with  an  obturator  ;  the 
club-shaped  end  of  which  possesses  on  the  side  two  furrows,  which 
continue  the  communication  between  the  atmospherical  air  and  that 
in  the  rectum,  and  prevent  by  this  the  suction-attaching  of  the 
mucous  membrane  through  the  negative  compression,  which  is  caused 
by  the  extraction  of  the  obturator. 

'  After  taking  out  the  obturator  from  the  tube,  the  light-bearer 
is  introduced.  This  consists  of  a  stick  pierced  through  its  whole 
length,  which  projects  so  far  into  the  tube  that  the  electrical  lamp 
fixed  to  it  remains  at  a  distance  of  1  cm.  from  the  rectal  end  of 
the  tube.  To  prevent  overheating,  between  the  stick  and  the  tube 
there  is  a  distance  of  some  millimetres.  The  whole  stick  is  J&xed 
to  a  ring,  which  is  fitted  air-tight  to  the  conical  end  of  the  tube, 
and  bears  a  small  faucet  to  enable  it  to  be  fixed  to  the  conus  by  a 
bayonet  apparatus.  A  glass  plate  fixed  in  a  metal  capsule,  "  the 
window,"  can  also  be  fixed  by  a  bayonet  apparatus  to  the  light- 
bearer,  and  then  the  tube  is  closed  air-tight. 

'  To  the  complete  contrivance  we  require  also  an  accumulator 
and  a  Rheostat. 

'  The  lamp  employed  does  not  get  very  warm,  and  burns  about 
4  volts.' 

The  evening  before  the  day  of  examination,  and  on  the  day  itself, 
about  three  hours  before  the  execution  of  the  rectoscopy,  an  enema 
is  administered  consisting  of  one  litre  of  a  physiological  solution  of 
chloride  of  sodium.  The  bladder  is  then  emptied.  The  best  posi- 
tion for  the  patient  is  the  knee-breast  situation  (Schreiber),  so  that 
the  back  has  an  inclination  from  the  pelvis  to  the  neck,  with  a  con- 
cavity in  the  lumbar-region,  so  that  the  legs  with  the  hips  form  an 
acute  angle. 

If  the  anus  be  sensitive  it  is  rubbed  with  a  piece  of  cotton  wool, 
dipped  into  a  solution  of  3  per  cent,  of  eucaine  or  of  2  per  cent,  of 
cocaine ;  an  injection  of  the  same  solution  is  made  into  the  rectum. 
The  lightly  warmed  and  well-oiled  tube  is  next  pushed  on  about 


SOME  AFFECTIONS  OF  THE  RECTUM.  969 

4r  cms.,  then  the  obturator  is  pulled-out,  and  the  lamp  communi- 
cating with  the  accumulator  is  placed  in  the  instrument,  so  that  it 
is  close  to  the  part  of  the  tube  situated  next  to  the  spine.  This 
arrangement  prevents  the  lamp  from  becoming  dirty.  Meanwhile 
an  assistant  affixes  the  insufflator  to  the  tube.  Now  the  range  of 
vision  is  lighted,  in  order  to  observe  whether  the  wrinkles  of  the 
anus  are  expanded  by  the  pressure  of  the  exterior  air.  If  this  be 
the  case,  put  the  tube  about  1 1  cms.  into  the  rectum  now  expanded 
by  the  air,  twisting  and  pushing  it  lightly,  and  keeping  it  well  in 
view.  Here,  according  to  Schreiber,  is  the  beginning  of  the  sigmoid 
flexure ;  that  this  may  be  perceived,  the  outer  end  of  the  tube  must 
be  lifted  a  little,  in  order  to  be  able  to  enter  into  the  iutroitus 
flexurae.  This  must  be  sought  by  controlling  the  instrument  and 
moving  it  backwards,  forwards,  and  sideways.  Generally  the 
entrance  is  excentric,  and  only  very  seldom  is  it  centrally  situated. 

Success  depends  on  this  part  of  the  examination. 

If  the  entry  into  the  sigmoid  flexure  be  successfully  carried  out, 
the  other  procedure  is  like  that  employed  by  Kelly  or  Schreiber.  To 
find  the  introitus,  the  window  is  fixed  to  the  tube,  and  by  cai-efully 
pushing  forward  the  latter,  air  is  pumped  into  the  rectum.  By  this 
means  the  introitus  opens,  and  is  visible,  so  that  there  is  no  difiiculty 
in  entering  it.  Then  the  window  is  taken  off,  in  order  to  observe 
whether  the  flexure  under  the  pressure  of  the  exterior  air  expands, 
and  if  this  does  not  happen  the  window  must  be  attached  again, 
and  the  expansion  effected.  After  this,  nothing  prevents  the  passage 
of  the  tube  still  further,  and  there  is  but  little  distress  or  pain 
to  the  patient. 

In  Fig.  612  (after  Strauss),  No.  1  shows  the  direction  of  the  appa- 
ratus on  entry.  No.  2  the  direction  when  the  ampulla  is  seen,  and 
No.  3  the  position  when  the  flexure  is  entered. 

Kelen  states  that  in  almost  every  instance  he  has  succeeded  in 
getting  into  the  flexure.  He  takes  Schreiber's  measurements  of  the 
rectum,  its  length  being  from  13  to  15  cms.,  and  that  of  the 
sigmoid  flexure  on  an  average  45  cms.,  while  at  a  distance  of  from 
11  to  13  cms.  the  plica  terminalis  of  Strauss  separates  the  rectum 
from  the  S.  romanum.  Also,  the  colour  of  the  ampulla  is  more  of 
a  light  rose,  and  the  shape  of  a  cupola ;  the  view  of  the  sigmoid 
flexure  is  narrower,  and  the  mucous  membrane  has  a  great  number 
of  looser  wrinkles.  The  difference  between  the  two  is  easily  recog- 
nized. Kelen  enumerates  the  therapeutical  advantages  which 
follow  from  the  differential  diagnosis  of  diseases  situated  in  the  two 


970 


DISEASES   OF   WOMEN. 


positions,    such    as   hsemorrhage,   abnormal   states   of    the  mucous 
membrane    (as  ulcers),    and    the    application  of  the    cautery   or   a 


Fig.  612. — Sno-wiNa  the  Passage  of  the  Instetjment. 
Arrows  mark  the  directions  iu  which  the  proctoscope  is  passed. 

caustic.  Most  important  of  all  is  the  insuring  of  a  high  enema  by 
the  passage  through  the  recto-romanoscope  of  a  thin  stomach  tube, 
which  will  permit  of  the  removal  of  the  instrument,  and  insures 
the  certainty  of  the  injection  passing  beyond  the  ampulla. 

Proctitis — Causation  and  Symptoms. 

Inflammation  of  the  rectum  in  women  may  be  due  to  spread  of 
infection  from  vaginal  discharges,  may  arise  from  the  irritation  of 
impacted  faeces,  foreign  bodies,  or  threadworms,  or  may  be  caused 
by  a  chill,  or  supervene  during  an  attack  of  zymotic  fever. 

We  have  already  referred  to  the  spread  of  gonorrhceal  infection 
from  the  vagina  to  the  rectum.  Fitsch,  in  explanation  of  the 
obstinate  nature  of  gonorrhceal  proctitis,  refers  to  the  persistence  of 
the  gonococcus  in  the  discharge,  and  he  thinks  that  many  of  the 
supposed  specific  ulcers  of  the  rectum  are  really  due  to  gonorrhceal 
virus,  the  cocci  being  found  six  months  after  the  original  attack. 

The  symptoms  are  pain,  heat,  sense  of  fulness  in  the  rectum,  with 
tenesmus  and  the  passage  of  mucus,  and  sometimes  blood.  Irrita- 
bility of  the  bladder  is  of  common  occurrence,  and  sometimes  cystitis. 


SOME  AFFECTIONS  OF   THE  RECTUM.  971 

Treatment. — We  must  first  remove  or  treat  the  cause.  The 
administration  of  repeated  doses  of  saline  aperients  has  often  a 
beneficial  eftect  iix  cutting  short  an  attack,  also  irrigation  of  the 
rectum  with  hot  boracic  lotion  and  laudanum.  For  the  distressing 
symptoms,  the  application  of  leeches  round  tlie  anus,  eucaine  or  cocaine 
suppositories,  and  hot  fomentations  combined  with  rest  in  bed,  will 
afford  relief.  The  rectum  should  be  washed  out  with  boracic  lotion 
after  each  evacuation.  Should  the  infection  be  due  to  gonorrhoea, 
stronger  disinfectant  lotions,  such  as  mercuric  perchloride  (yo  of  a 
grain  to  the  ounce)  or  permanganate  of  potash,  should  be  used,  and 
perfect  cleanliness  enforced. 

Impaction  of  Faeces  and  Fsecal  Tumours. 

Experience  teaches  us  how  extremely  careful  we  must  be,  in  cases 
in  which  obscure  abdominal  symptoms  are  present,  not  to  overlook 
the  possibility  of  a  fsecal  accumulation  in  some  portion  of  the  intes- 
tine. A  fsecal  tumour  may  he  mistaJcen,  through  the  signs  and  symjjtoms 
it  causes,  for  ascites,  malignant  tumour,  ovarian  dropsy,  and  aneurysmal 
enlargements  of  the  abdominal  aorta.  Many  times  fsecal  accumulations 
in  the  rectum,  the  result  of  habitual  neglect  of  the  bowel  in  women, 
aggravate,  if  they  have  not  brought  about,  various  forms  of  uterine 
disorder.  It  is  always  well  for  the  practitioner  to  be  on  his  guard, 
and  to  recollect  that  the  presence  of  a  fsecal  accumulation  in  the  hoioel 
is  quite  consistent  with  semi-liquid  motions  and  a  certain  degree  of 
response  to  laxative  or  aperient  medicines.  A  faecal  concretion  may 
exist  anywhere  in  the  colon,  and  either  at  the  side  of  it,  or  possibly 
by  tunnelling  the  mass,  this  semi-solid  evacuation  may  escape. 

When  there  are  symptoms  of  obstruction,  and  on  examination 
the  rectum  is  found  blocked  with  a  hard  mass  of  faeces,  the  bowel 
should  be  emptied  by  the  finger  or  scoop  under  an  anaesthetic. 
The  amount  of  faecal  matter  that  may  come  away  in  these  cases  is 
astonishing.  In  such  cases  the  sphincters  should  be  thoroughly 
dilated  with  the  hand  under  anaesthesia,  and  the  masses  removed. 
For  this  purpose  a  rectal  spoon  may  be  employed.  Should  a  patient 
suffer  from  stricture  or  ulcer  she  is  tempted  to  encourage  such 
accumulation  rather  than  permit  the  bowel  to  move.  When  the 
bowel  has  been  emptied,  an  injection  of  olive  oil  and  thin  gruel 
should  be  administered.  In  a  most  interesting  and  obscure  case  of 
suspected  malignant  abdominal  tumour  associated  with  emaciation 
and  haemorrhage,  the  bowel  was  emptied  in  this  manner,  the  tumour 


972  DISEASES   OF   WOMEN. 


disappeared,  and  the  patient  was  permanently  relieved.  It  is  not 
uncommon  to  remove  from  the  rectum  of  a  female  patient  some 
foreign  body  such  as  a  fish  bone,  a  piece  of  wood,  or  a  hairpin, 
the  presence  of  which  has  obscured  the  diagnosis.  The  possibility 
of  this  cause  of  a  rectal  or  ischio-rectal  abscess  should  not  be  over- 
looked. Thorough  dilatation  of  the  sphincters  under  anaesthesia  as 
a  preliminary  step  iu  the  treatment  of  obstinate  and  chronic  con- 
stipation has  already  been  alluded  to. 

Abscess. 

This  is  of  frequent  occurrence,  and  always  demands  early  incision 
and  evacuation,  owing  to  its  tendency  to  spread  and  form  fistulse. 

It  may  arise  as  the  result  of  injury  following  the  passage  of  a 
foreign  body,  such  as  a  fish  bone,  or  bacterial  invasion  of  a  sebaceous 
follicle,  a  small  abrasion,  tear,  or  fissure ;  from  suppuration  in 
extravasated  blood,  a  thrombosed  pile,  or  from  auto-infection. 

Varieties. — The  commonest  forms  are  follicular,  subcutaneous, 
and  ischio-rectal ;  submucous,  or  beneath  the  rectal  mucous 
membrane,  and  pelvic,  where  suppuration  takes  place  above  the 
levator  ani  and  between  it  and  the  rectum,  also  occur. 

Treatment. — Immediate  incision  and  complete  evacuation  of 
contents,  with  breaking  down  of  all  loculi,  followed  by  antiseptic 
packing  and  rest  in  bed,  are  always  indicated  to  prevent  the  forma- 
tion of  a  fistula.  By  passing  the  finger  into  the  rectum  and  pressing 
outwards  the  abscess  may  be  made  more  prominent,  and  in  order  to 
allow  free  drainage  a  crucial  or  T-shaped  incision  should  be  made, 
care  being  taken  to  carry  the  incision  the  whole  length  of  the 
inflamed  area,  and  also  not  to  wound  the  sphincter  muscle. 

A  submucous  abscess  should  be  opened  from  within  at  its  most 
dependent  point,  but  the  pelvic  rectal  abscess  should  be  drained 
by  a  free  incision  through  the  ischio-rectal  fossa,  the  abscess  being 
pressed  downwards  by  the  finger  in  the  rectum. 

Fistulse. 

Causation. — Injuries,  foreign  bodies,  zymotic  fevers,  haemorrhoids, 
syphilis,  tubercle.  They  may  be  intra-  or  extra-rectal  in  their 
origin,  the  primary  abscess  or  ulceration  commencing  in  the  mucous 
membrane,  in  the  submucous  tissue,  in  the  subcutaneous  cellular 
tissue  about  the  anus,  or  more  deeply  in  the  ischio-rectal  fossa. 

Fistulse  are  complete,  the  internal  opening  into  the  bowel  being 


SOME  AFFECTIONS   OF   THE  RECTUM.  \)TA 

either  above  the  internal  sphincter  or  more  commonly  between  it 
and  the  external ;  blind  external,  which  is  a  blind  external  canal,  as 


Fig.  (I]o. — RiccTAL  Dihector  and  Piiobe. 

it  has  no  internal  aperture  ;  and  hlind  internal,  which  has  no  external 
opening.  The  direction  of  the  sinus  of  the  latter  fistula  may  be 
suspected  by  the  position  of  the  external  orifice  ;  if  this  be  posterior 
to  the  transverse  axis  of  the  anal  opening,  the  fistulous  aperture  is 
behind  the  middle  line,  while,  if  the  external  aperture  be  in  front  of 
the  transverse  axis,  the  sinus  is  straight,  and  the  internal  opening  is 
directly  opposite  to  the  external  (Goodsall). 

In  the  case  of  a  JiorsesJioe  fistula  there  are  two  apertures,  usually 
posterior  to  the  anus,  communicating  with  each  other  by  a  curved 
or  crescentic  canal. 

As  regards  fistula,  there  are  some  axioms  it  is  well  to  remember. 
All  abscesses  about  the  region  of  the  anus  and  perineum  should,  as 
has  ah-eady  been  said,  be  opened  early.  Too  free  division  of  the 
sphincter  in  women  may  result  in  difliiculty  of  retaining  flatus  or 
faeces.  In  cases  of  fistula  complicated  by  tubercular  phthisis  it  is 
not  advisable  to  operate  unless  the  latter  disease  be  arrested  and 
the  patient's  strength  returning. 

A  fistula,  whether  complete  or  incomplete,  should  not  be  temporized  with  • 
in  the  large  proportion  of  cases  delay  only  leads  to  extensive  buiTowing,  and 
renders  the  ultimate  division  a  more  serious  step.  A  fistula  should  be 
thoroughly  divided  with  the  sphincter  muscle.  In  operating,  a  careful  search 
should  be  made  for  by-channels  and  burrowing  sinuses  in  the  track  of  the 
parent  canal.  These  also  should  be  freely  opened.  A  bfind  internal  fistula 
should  be  made  complete,  and  the  sphincter  divided.  Subsequent  dressings 
should  not  be  over  done,  as  they  are  apt  to  irritate  and  create  discharge,  or 
delay  the  heahng  process.  Some  sterilized  wool  is  the  best  dressing,  and  the 
wound  can  be  kept  clean  with  any  antiseptic  solution. 

Should  the  fistula  be  of  the  '  horseshoe '  kind,  it  must  be  opened  in  the 
manner  advised  by  Swinford  Edwards :  '  Pass  through  the  internal  orifice  a 
probe-pointed  director,  and  on  its  point  incise  the  skin  in  tbe  middle  line 
behind ;  now  push  the  director  through  and  sHt  up.  Secondly,  slit  up  the 
lateral  sinuses  on  directors  passed  in  at  each  external  opening  and  brought 
out  through  the  dorsal  incision.'  Thus  a  T-shaped  incision  results.  Also, 
ofi'-siuuses  can  be  opened  from  the  main  track,  and  the  sphincters  are  wounded 
as  little  as  possible.  Small  fistulee  may  be  cured  by  the  application  of  the 
galvano-cautery. 


974  DISEASES   OF   WOMEN. 


Haemorrhoids. 

Womea  are  specially  liable  to  haemorrhoicls.  I  will  not  delay- 
here  to  enter  into  the  question  of  the  causation  and  structure  of 
piles.  It  is  sufficient  to  say  that  external  haemorrhoids,  and  the 
resulting  tags  of  loose  skin  that  fringe  the  anus,  are  receptacles  for 
impure  discharges,  both  rectal  and  vaginal,  which  dry  in  the  chinks 
between  the  folds.  This  tends  to  cause  rectal  irritation,  to  lead  to 
fissure  and  pruritus  ani,  or  proctitis.  Internal  htemorrhoids  cause  a 
wearying  pain  and  distress  in  the  sacral  region,  often  extending  to 
the  thighs.  They  are  frequently  the  source  of  mental  depression 
and  irritation.  If  they  bleed,  they  deteriorate  the  general  health, 
and  in  many  cases,  at  the  time  of  the  climacteric,  may  lead  to  a 
serious  degree  of  anaemia.  The  general  treatment  and  ordinary 
therapeutic  measures  to  be  adopted  in  the  case  of  piles  are 
summarized  under  the  head  of  '  General  Therapeutic  Hints.' 

Question  of  Operation  during  Pregnancy,  and  where  there  is  an 
Associated  Uterine  Affection. 

Unless  there  be  some  good  reason  to  the  contrary,  it  is  best  not 
to  operate  on  a  pregnant  woman  for  piles.  But  if  the  haemorrhage 
be  severe,  then  the  piles  should  be  removed,  and  the  remote  risk  of 
miscarriage  occurring  must  be  taken.  It  may  be  also  looked  upon 
as  a  safe  rule  that  where  there  is  any  attendant  uterine  affection, 
such  as  a  severe  erosion,  endometritis,  or  a  displacement,  it  is  better 
to  rectify  first  the  uterine  error  before  proceeding  to  operate  for  the 
internal  hsemorrhoids. 

With  regard  to  the  choice  of  operation,  decidedly  the  safest  and  most 
satiafactory  is  by  ligature  transplantation.  I  have  never  had  occasion  to 
regret  operating  by  this  method,  either  as  regards  the  effectiveness  of  the 
cm'e  or  the  freedom  from  hsemorrhage.  -  In  all  the  cases  I  have  done,  I  have 
never  had  a  fatal  issue,  though  this  retrospect  includes  every  conceivable 
degree  of  hsemorrhoidal  condition  and  attendant  prolapse.  No  matter  how 
brilliant  and  pleasant  may  be  the  results  in  the  large  proportion  of  cases  with 
the  clamp,  or  clamp  and  cautery,  the  surgeon  may  in  some  unexpected  cases 
be  caught,  and  find  it  difficult,  if  not  impossible,  to  stop  the  hsemorrhage. 
'  I  do  not  thinh^  says  W.  AlUngham,  '  in  the  whole  range  of  surgery  there  is 
any  procedure  vmrthy  the  nam,e  of  "  operation  "  tohich  can  show  a  greater 
amount  of  success  or  a  smaller  death-rate  than  the  ligature  of  internal 
hemorrhoids.''  * 

*  Of  4013  cases  of  haemorrhoids  ligatured  at  St.  Mark's  Hospital,  there  were 
five  cases  of  tetanus  and  one  case  of  doubtful  pyaemia.     The  death-rate  from  all 


SOME  AFFECTIONS  OF  THE  RECTUM.  975 

The  occurrence  of  the  menstrual  period  must  be  inquired  into 
before  operating.  It  is  not  prudent  to  operate  on  the  rectum  when 
menstruation  is  approaching  ;  we  should  select  the  time  between 
two  periods. 

Operations  for  Haemorrhoids. 

The  appliances  necessary  for  the  ordinary  minor  operative  measures 
required  in  affections  of  the  rectum  are — 

Rectal  grooved  director. 
Pile  scissors,  flat  and  curved. 
Serrated  tenaculum,  with  catch. 
Pile  forceps. 

,j    hook. 
Straight  spring  scissors. 
Scalpels. 

Blunt  and  probe-pointed  bistouries. 
Curved  needles. 
Needle-holder. 

Some  Pean's  and  Kocher's  forceps. 
Paquelin's  or  the  galvano  cautery. 

Excision  of  External  Haemorrhoids. — This  is  best  effected  with 
the  straight  spring  scissors  (Fig.  614).  The  pile  is  simply  snipped 
off.  If  there  be  loose  tags  of  skin  which  fringe  the  anus,  they  are 
seized  and  cut  off  in  the  same  way.  Too  much  integument  must 
not  be  cut  away  lest  contraction  of  the  anal  orifice  result.  If  a 
woman  be  suffering  severe  pain  from  a  congested  and  inflamed  pile, 
it  should  be  incised.  AVith  the  thumb  and  forefinger  it  is  held, 
steadied,  and  a  curved  bistoury  is  passed  through  it.  The  contained 
coagulum  can  be  squeezed  out.  Warm  anodyne  fomentations  and 
soothing  ointments  can  then  be  used.  Chlorethyl  spray  is  useful 
in  making  such  an  incision,  or  in  cutting  off  the  folds  of  skin. 

Operation  on  Internal  Piles  by  Ligature. — Having  regulated  the 
patient's  bowels  for  a  few  days  previously,  an  enema  is  administered 
early  on  the  morning  of  the  operation,  thorough  evacuation  of  the 
bowel  is  secured,  and  immediately  before  operation  the  rectum  is 
washed  out  with  a  warm  solution  of  boric  acid.     An  anaesthetist, 

causes  in  operation  by  ligature  in  the  hospital  during  a  period  of  over  forty  years 
was  1  in  670  ;  four  of  the  five  cases  of  deatli  from  tetanus  occurred  during  a  year 
(1858)  when  tetanus  was  rife  in  London.  The  author  has  never  had  a  fatal  case 
arising  out  of  the  operation  of  ligature. 


976 


DISEASES    OF   WOMEN. 


assistant,  and  nurse  are  required.  The  patient  is  brought  well  to 
the  edge  of  the  table  and  placed  in  the  dorsal  position  opposite 
a  good  light,  the  thighs  being  well  apart  and  supported  by  leg-rests, 
with  a  folded  sheet  or  waterproof  under  the  buttocks.     When  she 


Fi(i.  614. — Stkaight  (Spring)  Pile  Scissors. 


Fig.  615.— Pile  Fork 


Fig.  616. — Pile  Scissors  bent  on  the  Flat. 


Fig.  618. — Pile  Forceps. 


is  fully  anaesthetized,  the  sphincters  should  be  well  dilated,  the  piles 
exposed,  and  the  surface  of  the  bowel  cleansed. 

The  nurse  has  beside  her  a  basin  with  a  formalin  solution,  con- 
venient-sized gauze  dabs,  and  some  catch   forceps  to  hold  these. 


SOME  AFFECTIONS  OF   THE  RECTUM.  ^11 

An  irrigator  is  useful  for  cleansing  the  bleeding  surface,  and  for 
washing  away  clots  and  douching. 

Each  pile  (commencing  with  those  nearest  the  anal  aperture  and 
on  the  lower  rectal  wall)  is  seized  with  the  fork  or  pile-forceps,  and 
drawn  well  down  and  out  from  the  coat  of  the  intestine.  Tlie  pile 
scissors  (Fig.  G16)  bent  on  the  flat,  or  the  spring  scissors  (Fig.  614), 
is  now  laid  flat  against  the  rectal  tunic,  and  the  blades  are  made  to 
embrace  the  sides  of  the  ha'morrhoid,  reaching  to  the  summit  of  the 
pile,  and  leaving  its  upper  connection  with  the  bowel  free.  With 
a  few  strokes  of  the  scissors  the  division  of  the  mucous  fold  is 
effected.  The  surgeon,  laying  down  the  scissors,  transfers  the  pile 
forceps  to  his  assistant,  and,  taking  a  cumol  gut  ligature,  carries 
it  well  up  to  the  angle  of  the  wound  he  has  made,  at  the  junction 
of  the  semi-detached  pile  with  the  rectal  wall.  He  secures  the 
ligature  flrmly,  and  cuts  off"  the  ends  close  to  the  pile.  The  pile  is 
now  completely  removed,  not  too  close  to  the  ligature,  lest  the  latter 
be  cut.  He  proceeds  in  this  manner  with  each  pile.  Any  spurting 
vessel  he  secures  by  forcipressure  or  tine  gut  ligature.  He  next 
inspects  the  anus,  and  removes  any  superfluous  folds  of  skin  with 
the  scissors.  The  severed  and  retracted  mucous  membrane  of  the 
bowel  is  now  brought  down  to  the  edge  of  the  anus,  and  fixed  there 
with  a  circumferential  interrupted  cumol  gut  suture,  and  when  the 
operation  is  completed  there  is  perfect  adaptation,  and  no  raw 
surface  is  exposed.  The  rectum  is  washed  out  with  formalin  solu- 
tion, and  the  wound  thoroughly  dried  and  cleansed.  A  thin  roll  of 
iodoform  gauze,  soaked  in  sterilized  oil,  with  a  string  attached,  is 
passed  for  about  four  inches  into  the  bowel.  A  piece  of  iodoform 
gauze  with  a  compress  of  cotton  wool  is  applied  under  a  firm 
T-bandage,  an  opiate  is  given,  and  the  bowel  is  not  moved  for  at 
least  five  days  after  the  operation.  I  find  the  following  plan 
answers  well.  After  recovery  from  the  anaesthetic,  one  grain  of 
opium  is  given  in  pill ;  after  an  hour's  interval  a  second  grain,  and 
half  a  grain  every  six  hours  subsequently  for  the  first  thirty-six 
hours ;  after  this,  one  quarter  to  half  a  grain  twice  in  the  twenty- 
four  hours  is  sufficient.  On  the  sixth  morning  an  injection  of  six 
ounces  of  olive  oil  is  given,  and  after  a  short  time  th6  bowel  is 
moved  by  an  emollient  enema  of  strained  gruel  and  olive  oil.  The 
rectum  may  be  douched  out  daily  with  some  warm  boric  acid  lotion, 
and  it  may  be  well  after  some  days  to  explore  it  gently  with  the 
finger  anointed  with  some  antiseptic  lard,  lest  there  be  any  tendency 
to   contraction.     The  patient   remains  in  bed    until   the   ligatures 

3   R 


978 


DISEASES    OF   WOMEN. 


separate,  and  after  this  she  may  lie  on  a  sofa  for  a  few  days  before 
moving  about.  Careful  instructions  should  be  given  regarding  the 
daily  evacuation  of  the  bowel,  and  the  use  of  a  little  hazeline  and 
boric  acid  injection  after  a  motion  is  beneficial.  Any  swelling 
about  the  anus  from  the  cutting  off  of  external  hsemori'hoids  quickly 
subsides  by  attention  to  cleanliness  and  the  use  of  hazeline  and  an 
astringent  ointment. 

W.  Whitehead's  Operation. — This  is  an  operation  of  ablation.  I  have  on 
several  occasions  adopted  the  plan  he  advocates  of  attaching  the  sound  mucous 
membrane  above  the  pile  area  to  the  skin.  I  do  not,  however,  follow  his 
method  in  its  entiret}^  being  quite  satisfied  with  my  results  by  the  above 
method.  In  the  case  of  unusual  hfemorrhage  I  arrest  it  by  gut  ligatures, 
carried  deeply  through  the  tissues.  It  is  far  safer  to  trust  to  ligature  in  such 
cases  than  to  torsion. 

The  following  is  Whitehead's  operation  : — 

The  patient  being  secured  in  the  lithotomy  position  by  Clover's  crutch,  and 
the  sphincters  fully  dilated,  by  the  use  of  scissors  and  dissecting  forceps  the 
mucous  membrane  is  divided  at  its  junction  with  the  skin  round  the  entire 
circumference  of  the  bowel,  every  irregularity  of  the  skin  being  carefully 
followed.  The  external,  and  the  commencement  of  the  internal,  sphincters 
are  then  exposed  by  a  rapid  dissection,  and  the  mucous  membrane  and 
attached  hsemorrhoids,  thus  separated  from  the  submucous  bed  on  which  they 
rested,  are  pulled  bodily  down,  any  undivided  points  of  resistance  being 
nipped  across,  and  the  haemorrhoids  brought  below  the  margin  of  the  skin. 

The  mucous  membrane  above  the  haemorrhoids  is  now  divided  transversely 
in  successive  stages,  and  the  free  mai'gin  of  the  severed  membrane  above  is 
attached  as  soon  as  divided  to  the  free  margin  of  the  skin  below  by  a  suitable 
number  of  sutures.  The  mucous  membrane  should  be  separated  at  its  lowest 
point,  and  the  dissection  carried  laterally  from  below  upwards. 

Clamp  and  Cautery. — I  do  not  intend  to  enter  into  the  details  of  the  opera- 
tion of  clamp  and  cautery.  The  preliminaries  are  the  same  as  for  operation 
by  ligature ;  the  pile  is  broiight  down,  secured  by  the  clamp,  and  then  cut 
off  with  the  bent  scissors  (Fig.  616),  the  cautery  being  apphed  at  a  dull 
heat.  The  piles  can  also  be  removed  by  Downes's  thermo-cautery  clamp  (see 
Fig.  351,  p.  499). 


Fig.  619. — Pollock's  Clamp  pok  ckushing  Hemorrhoids. 


To  Pollock  we  are  indebted  for  the  suggestion  to  remove  piles  by  crushing. 
The  steps  of  the  operation  are  as  follows  :  The  sphincters  are  first  dilated. 


SOME  AFFECTIONS  OF  THE  RECTUM.  97!t 


Tlie  pile  is  ilmwii  into  tho  clamp,  and  is  crushed  by  tightly  screwing  up  tlie 
bar  of  steel,  keeping  it  thus  applied  for  the  space  of  half  a  minute.  The 
projecting  portion  of  the  pile  is  removed  with  scissors.  There  can  be  no 
doubt  that  crushing  is,  generally  speaking,  an  expeditious  and  comparatively 
painless  method  of  removing  the  piles.  Still,  we  are  not  free,  in  a  certain 
percentage  of  cases,  from  the  risk  of  bleeding,  and  in  the  case  of  large 
heemorrhoids,  or  when  the  patient  lives  at  a  distance,  the  ligature  gives 
greater  security. 

Treatment  by  Nitric  Acid. — -Some  surgeons  treat  piles  by  the  application  of 
nitric  acid.  For  venous  haemorrhoids  of  a  medium  size  this  plan  may 
answer  well. 

To  plug  the  Rectum  for  Haemorrhage. — The  following  method  of  plugging 
the  rectum,  originally  advised  b}^  Alliugham,  when  such  is  required  will  be 
found  by  far  the  best :  A  good-sized  conical-shaped  sponge  is  secured  by 
passing  a  piece  of  strong  silk  ligature  through  its  apex.  The  sponge  is  then 
wetted  and  squeezed  dry,  and  the  interstices  filled  with  alum  or  sulphate  of 
iron.  Guided  by  the  fore-finger  of  the  left  hand,  the  conical  end  of  the  sponge 
is  pushed  well  into  the  rectum  for  the  extent  of  five  inches,  and  the  silk  cord 
hangs  from  the  a;;us.  The  space  below  the  sponge  is  now^  filled  with  cotton- 
wool, on  which  is  sprinkled  more  of  the  alum  or  sulphate  of  iron.  The  ends 
of  the  string  hanging  from  the  anus  are  now  taken  in  the  left  hand,  and 
traction  is  made  on  the  sponge  while  the  cotton-wool  is  pressed  up  against  it 
with  the  finger  of  the  other  hand.  The  eifect  of  the  counter-pressure  is  to 
spread  out  the  sponge  '  umbrella-shaped,'  and  to  compress  the  wool  tightly. 
This  plug  may  remain  in  for  a  period  of  from  eight  to  ten  days.  If  a  patient 
be  troubled  with  flatus,  a  flexible  catheter  or  rectal  tube  may  be  introduced 
through  the  wool  and  sponge  or  at  the  side,  and  this  prevents  any  troublesome 
distension.     Opiates  at  the  same  time  should  be  given. 

Ulceration  and  Stricture. 

Ulceration  of  the  Rectum. — Fissure  and  ulceration  of  the  rectum 
are  frequently  met  with  in  women,  both  being  complicated  by  such 
affections  of  the  uterus  as  endometritis,  subinvolution,  laceration  of 
the  cervix,  versions  and  flexions.  Operative  interference  with 
rectal  disorder  is  likely  to  pi'ove  unsuccessful  as  long  as  the  uterine 
complication  remains  unrelieved. 

Symptoms. — If  a  woman  complain  of  vesical  irritation,  with 
rectal  distress  and  pain,  both  on  deftecation  and  micturition,  and 
no  uterine  condition  be  present  to  account  for  these  symptoms,  the 
rectum  should  be  carefully  examined  for  fissure  or  ulcer.  It  will  be 
well,  if  the  rectum  be  sensitive,  to  do  this  under  an  antesthetic. 

Treatment. — The  treatment  of  painful  ulcer  or  fissure  resolves 
itself  into  palliative  and  radical. 

Under  the  head  of  palliative  we  include  rest,  due  attention  to, 


980  DISEASES   OF   WOMEN. 

and  regulation  of,  the  bowel,  the  administration  of  mild  laxatives, 
such  as  any  of  those  already  recommended,  to  secure  an  efficient 
but  gentle  aperient  effect ;  the  use  locally,  either  in  lotion  or 
ointments,  of  sedative  and  astringent  drugs,  as  opium,  morphia, 
cocaine,  belladonna,  bismuth,  calomel,  tannic  acid,  adrenalin  or  rena- 
glandine,  hazeline,  perchloride  of  mercury,  and  nitrate  of  silver ;  in 
severe  cases,  the  careful  application  to  the  ulcer  of  either  the  acid 
nitrate  of  mercury  or  nitric  acid.  The  radical  treatment  consists 
in  operation  by  incision  through  the  entire  lase  of  the  ulcer  and 
fissure,  loith  the  division  of  the  underlying  sphincter. 

The  more  we  reflect  on  the  insidious  progress  of  rectal  disease, 
the  obscure,  and  in  many  instances  remote,  symptoms  which  attend 
incipient  ulceration,  stricture,  or  malignancy,  as  well  as  the  reflex 
disturbances  which  are  apt  to  divert  our  attention  from  the  rectum 
to  some  other  organ,  the  more  necessary  the  injunction  to  the 
medical  adviser  to  look  to  the  rectum  when  such  symptoms  as  those 
of  dysenteric  and  morning  diarrhcea,  Jelly-like  discharge,  colicky  pains, 
and  tenesmus  are  complained  of. 

Stricture. — Frequently  the  ulcer,  or  commencing  stricture,  is  not 
close  to  the  anus,  but  some  two,  three,  or  four  inches  from  its 
margin,  so  that  the  examining  finger  has  to  be  passed  well  up  the 
bowel  before  it  can  be  detected.  Women  sufier  more  than  men 
from  stricture  of  the  rectum.  It  seems  from  statistics  that  con- 
stitutional syphilis  in  women,  if  it  affect  the  rectum,  is  particularly 
liable  to  cause  stricture. 


4'-<«^ 


i-_.  „_„. — L„„^..„  L,^^.„iES,  Conical  and  Bulbous. 

Verneuil's  operation  of  division  of  the  entire  stricture,  or  linear 
rectotomy,  is  that  most  frequently  practised.  In  dilatation  of  a 
stricture,  soft,  bulbous-pointed,  hollow  bougies  may  be  used;  the 
surgeon  shovild  have  some  of  these  of  different  sizes  by  him ;  and  it 
is  safer  for  him  to  dilate  the  stricture  rather  than  to  permit  the 
patient  to  pass  the  bougie  herself.  The  larger  sizes  of  my  uterine 
bougies  will  be  found  to  answer  well  for  the  surgeon's  use.  They 
must  be  employed  with  gentleness.    . 


SOME  AFFECTIONS    OF    THE   RECTUM.  H81 


Muscular  '  spasmodic  stricture  of  the  rectum '  is  a  very  doubtful 
affection ;  moreover,  in  many  of  these  cases  of  '  spasm '  we  have 
simply  to  deal  with  a  neurotic  reflex  irritation,  which  causes  a  tonic 
contraction  of  the  sphincters,  generally  exaggerated  by  the  presence 
of  hard,  dry,  and  impacted  faeces.  That  there  is  no  real  stricture 
to  necessitate  dilatation  is  at  once  proved  by  an  ana'sthetic. 

Malignant  Disease. 

Two  varieties  are  met  with  :  (1)  Epithelioma;  (2)  Carcinoma. 

Epithelioma  begins  externally  in  the  skin  near  the  anus  or  in 
the  anal  canal,  and  tends  to  spread  externally,  implicating  the  anus 
and  perineal  skin,  and,  at  a  later  stage  of  the  disease,  causing 
infection  and  enlargement  of  the  inguinal  glands.  It  may  cause 
anal  stricture,  though  incontinence  sometimes  occurs  from  destruc- 
tion of  the  sphincter.  Two  varieties  are  met  with,  viz.  the  warty 
and  ulcerative  ;  the  former  being  recognized  by  its  hard,  infiltrating 
base,  and  the  latter  by  its  indurated,  elevated,  and  rampart-like 
edges.  The  progress  of  the  disease  is  slow,  and  the  prognosis  is 
favourable  in  cases  of  early  excision. 

Carcinoma  commences  in  the  epithelium  of  the  rectal  mucosa, 
and  microscopically  is  identical  with  the  cells  of  Lieberkuhn's 
follicles.  The  disease  may  follow  simple  ulceration  or  stricture, 
but  the  onset  is  usually  very  insidious. 

Symptoms. — In  its  earlier  stages,  and  months  before  the  trouble 
is  suspected  or  diagnosed,  the  absence  of  any  marked  symptom  is 
common.  Perhaps  there  is  a  feeling  of  discomfort  in  the  rectum, 
with  aching  in  the  sacrum  or  thighs ;  sometimes  constipation,  and, 
later,  spurious  diarrhoea,  or  a  constant  desire  to  go  to  stool.  The 
so-called  '  morning  diarrhoea '  is  frequently  a  marked  feature,  and 
here  the  patient,  immediately  on  rising,  usually  passes  only  a  small 
slimy  motion  containing  much  mucus  and  perhaps  some  blood,  this 
being  followed  after  a  brief  interval  by  another  similar  evacuation. 
Slight  haemorrhage  is  sometimes  noticed,  but  any  marked  pain  is 
a  late  feature,  except  in  growths  in  the  lower  rectum,  implicating 
the  sensitive  anal  region. 

On  examination  per  anum  three  clinical  varieties  may  be  found  : 
(a)  Ulcerative,  which  is  distinguished  by  its  hard  raised  edges  and 
rugged  base.  (6)  Fungating,  where  a  large  mass  projects  into  and 
encroaches  on  the  lumen  of  the  bowel,  and  is  characterized  by  its 
soft  consistency,  with    a  readiness  to    bleed  on  examination,   and 


982  DISEASES  OF   WOMEN: 

is  surrounded  by  an  infiltrating  base,  (c)  Annular — this  is  usually 
a  well-marked  stricture  with  a  ring-like  infiltration  more  or  less 
completely  encircling  the  bowel ;  very  hard  to  the  touch,  and 
associated  with  ulceration  and  roughness  of  its  edges. 

Locally,  the  disease  tends  to  spread  outside  the  rectum,  and  to 
implicate  surrounding  organs — notably,  the  A'agina  .  and  uterus,  to 
which  it  becomes  fixed,  and  also  to  the  sacrum. 

Treatment. — Early  excision,  where  possible,  is  urgently  indi- 
cated, and  the  prognosis  after  radical  treatment  is  very  favourable 
in  early  cases  of  carcinoma  of  this  region.  Those  cases  suitable 
for  operation  are  where  the  gi'owth  is  localized,  quite  movable  (no 
matter  how  high  in  the  rectum),  and  not  fixed  to  any  surrounding 
parts.  This  question,  however,  cannot  always  be  settled  without 
examination  under  an  anaesthetic.  Even  if  the  posterior  vaginal 
wall  be  implicated  to  a  limited  extent,  the  afiected  portion  can  be 
removed,  and  operation  carried  out  with  every  hope  of  ultimate 
success. 

Perineal  Excision  is  limited  to  cases  of  disease  of  the  lower 
part  of  the  rectum,  and  is  now  more  or  less  abandoned  in  favour 
of  operation  by  the  dorsal  method.  The  latter  has  the  follow- 
ing advantages:  (1)  The  growths  of  the  upper  rectum  can  be 
readily  removed  if  movable,  (2)  There  is  greater  facility  of  re- 
moving glands  in  the  hollow  of  the  sacrum.  (3)  A  better  view  is 
obtained  of  the  field  of  operation.  (4)  There  is  less  danger  of 
wounding  surrounding  organs. 

Dorsal  Excision. — This  operation  is  usually  associated  with  the 
name  of  Kraske,  who  attacked  the  rectum  by  removing  the  left 
portion  of  the  two  lower  segments  of  the  sacrum.  Many  modifica- 
tions of  this  are  now  practised,  the  most  popular  being  excision  of 
the  coccyx  only  (Kocher) ;  or,  where  more  room  is  required,  the 
sacrum  is  divided  transversely,  and  the  two  lower  portions  removed 
(Bardenhauer). 

Operation. — The  bowels  having  been  previously  emptied,  and  the 
rectum  well  irrigated  with  an  antiseptic  lotion,  the  patient  is  placed 
on  her  left  side  in  the  semi-prone  position,  with  the  thighs  well 
flexed  on  the  abdomen. 

An  incision  is  made  in  the  mesial  line  to  a  point  midway  between 
the  top  of  the  coccyx  and  the  anus,  and  if  necessary  is  extended 
round  the  latter  in  cases  where  it  has  to  be  removed.  The  coccyx 
and  lower  part  of  the  sacrum  are  freed  from  their  ligamentary  aiid 
muscular  attachments,  and  with  the  aid  of  a  periosteal  elevator  the 


SOME  AFFECTIONS  OF   THE  RErTUM.  083 

veins  in  the  hollow  of  the  sacrum  are  carefully  separated  from  the 
bone — an  important  point  in  minimizing  hpemorrhage.  The  coccyx 
and  lower  two  segments  of  the  sacrum  are  removed,  and  this 
can  readily  be  effected  by  cutting  the  bone  with  an  Ameiican 
pruning  forceps.  A  good  view  of  the  rectum  is  now  obtained,  and 
as  much  bowel  as  necessary  can  be  liberated  and  brought  down  by 
opening  the  peritoneum  of  Douglas'  pouch  on  each  side  of  the 
rectum,  and  l)y  ligating  and  dividing  the  meso-rectum  in  sections. 
When  enough  bowel  is  thus  freed,  the  peritoneum  is  carefully 
closed,  and  the  rectum  is  divided  well  above  the  growth.  After 
this  the  lower  part  of  the  gut  can  readily  be  freed  by  rough  dissec- 
tion and  removed,  with  any  glands  felt  in  the  hollow  of  the  sacrum. 
When  the  sphincter  ani  is  not  removed,  the  bowel  can  be  brought 
down  and  sutured  in  position ;  or  if  any  portion  of  the  lower  rectum 
is  spared,  end  to  end  anastomosis  can  be  accomplished.  In  those 
cases  where  the  sphincter  has  been  sacrificed,  it  is  advisable  to 
suture  the  open  end  of  the  bowel  to  the  skin  at  the  upper  angle  of 
the  wound,  below  the  remaining  portion  of  the  sacrum.  With  an 
anus  in  this  position,  a  plug  can  be  conveniently  worn,  and  in  the 
sitting  posture  does  not  cause  the  discomfort  of  pressure,  as  is  the 
case  if  one  be  worn  when  the  bowel  is  brought  doNvn  and  sutured 
to  the  site  of  the  sphincter  ani. 

In  suturing  the  operation  wound,  it  is  essential  to  attend  care- 
fully to  the  closing  of  the  peritoneum,  and,  above  all,  it  is  most 
necessary  that  every  effort  should  be  made  to  bring  the  deeper 
parts  of  the  wound  into  apposition,  in  order  to  obtain  primary  union 
and  rapid  healing. 

After  operation  the  patient  should  be  kept  absolutely  at  rest, 
and  on  a  fluid  diet.  The  bowels  should  be  confined  for  five  days, 
after  which  an  evacuation  every  second  day  should  be  obtained 
nntU  complete  healing  has  taken  place.  A  preliminary  colotomy  is 
advocated  by  some  surgeons,  as  it  prevents  ftecal  contamination  of 
the  wound  after  excision,  but  by  care  the  bowels  can  be  kept  con- 
fined, and  the  wound  clean,  the  patient  thereby  being  saved  the 
suffering  entailed  by  two  operations. 

Colotomy  for  Advanced  Carcinoma. 

In  those  cases  where  it  is  impossible  to  attempt  extirpation 
owing  to  the  extent  of  the  growth,  it  is  advisable  to  lay  before 
the  patient   the  question  of  colotomy.      If  the  inguinal  operation 


984  DISEASES   OF    WOMEN. 

be  performed,  a  proper  spur  made,  and  the  operation  be  not  post- 
poned until  the  patient  is  in  extremis,  there  is  very  little  risk 
run.  With  a  properly  fitting  appliance,  flatus  and  fseces  can  be 
kept  well  under  control.  The  formation  of  this  artificial  anus 
greatly  relieves  such  symptoms  as  pain  and  constant  desire  to 
deftecate,  and,  moreover,  the  growth  being  freed  from  the  irritation 
of  passing  fseces,  septic  absorption  is  considerably  diminished,  the 
risk  of  obstruction  is  removed,  the  patient's  condition  generally 
improves,  and  life  is  undoubtedly  prolonged. 

Pruritus  Ani. 

Pruritus  ani  may  be  treated  on  the  same  pi-inciples  as  those 
followed  in  the  management  of  pruritus  vulvae.  As  in  this  latter 
troublesome  afiection,  pruritus  ani  has  its  origin  in  constitutional 
as  well  as  local  causes.  Some  cases  of  pruritus  ani  are  most  in- 
tractable. I  recently  had  such  a  case  in  which  nitric  acid,  carbolic 
acid,  and  the  actual  cautery  were  successively  applied  with  only 
temporary  relief.  Haemorrhoids  had  been  previously  removed. 
Here  removal  of  the  superficial  layer  of  the  skin  with  a  grafting 
razor  may  be  justifiable.  All  that  has  been  said  of  the  vulvar 
^  affection  applies  to  that  of  the  anus.  We  have,  however,  to 
remember  that  haemorrhoids,  fissure,  polypus,  thread-worms,  vaginal 
discharges,  or  syphilitic  skin  eruptions,  may  produce  the  itching,  and 
that  these  must  be  cured  before  we  can  hope  to  relieve  it.  All 
superfluous  tags  of  loose  skin  should  be  cut  off.  Scrupulous  cleans- 
ing of  the  part  night  and  morning  should  be  enforced,  A  hypnotic 
may  have  to  be  given,  such  as  trional  or  sulphonal,  and  a  rectal  plug 
worn  at  night  is  useful.  By  following  the  same  rules  as  have  been 
laid  down  in  pruritus  vulvae,  while  attending  by  local  measures  to 
the  anus  and  rectum,  and  not  neglecting  errors  of  a  constitutional 
character,  we  seldom,  however,  fail"  to  bring  about  a  speedy  cure. 

Procidentia. 

It  is  well  to  remember  that  procidentia  of  the  rectum  is  at  times 
associated  with  polypus  ;  and  the  practitioner  should  be  careful  not 
to  mistake  it  for  haemorrhoids.  Procidentia  occurs  perhaps  more 
frequently  in  women  than  in  men,  and  often  increases  to  a  large 
size.  The  plan  of  Van  Bruen  will  be  found  most  efl&cacious.  Longi- 
tudinal strips  are  made  in  the  protruded  intestine  with  a  Paquelin's 


SOME  AFFECTIONS    OF   THE  RECTUM.  985 

cautery,  avoiding  the  large  veins,  and  then  the  operator,  having 
first  oiled  the  intestine,  returns  it.  After  return  of  the  bowel,  he 
secures  further  contraction  of  the  anal  aperture  by  division  of  the 
sphincter  with  the  Paquelin's  knife  in  two  places,  and  stuffs  the 
wounds  with  oiled  gauze.  Longitudinal  and  circumferential  con- 
traction is  the  result. 

If  a  polypus  be  discovered  in  the  rectum,  torsion  or  ligature  will 
be  sufficient  to  remove  it  without  danger. 

Rectocele  has  been  already  referred  to  (see  pp.  283,  300-302). 

A  Few  General  Therapeutic  Hints. 

Soothing  Measures. — Great  relief  from  rectal  pain,  from  proctitis,  inflam- 
matory hfemorrhoids,  or  threatening  abscess,  is  often  secured  by  the  apiDlication 
of  leeches  round  the  anus.  A  warm  toast  poultice  is  a  ready  and  grateful 
form  of  stupe  to  apply  when  the  leeches  are  removed  after  incision  of  a  pUe. 
A.  piece  of  thick  toast  is  made,  on  which  boiling  water  is  poured.  The  toast 
is  squeezed  between  two  plates,  so  as  to  press  out  the  water,  supported  on  a 
handkerchief,  or  covered  with  a  piece  of  oiled  silk ;  it  is  laid  over  the  perineum, 
and  is  maintained  in  position  by  a  T-bandage.  A  piece  of  spongio  piline  may 
be  used  for  the  application  of  sedatives  to  the  anus.  It  is  a  clean  and  ready 
means  of  relieving  pain.  The  warm  sitz-bath  is  often  very  comforting  to  a 
patient,  or  the  steam  of  laudanum-water  placed  in  the  night  chair  on  which 
she  sits.  Suppositories  of  cocaine,  cocaine  and  belladonna,  or  eucaine  and 
cocaine  with  morphia,  are  valuable  as  local  sedatives.  Hazeline  with  adre- 
nalin is  an  admirable  astringent  remedy,  applied  externally  for  haemorrhoids. 
The  glycerols  of  tannin  and  of  lead  are  useful  external  applications  for  fissure 
and  haemorrhoids.  Goulard's  lotion,  in  combination  with  the  liquid  extract 
of  opium,  is  a  good  sedative  in  hsemorrhoidal  congestion  and  in  ulceration. 

Aperients. — In  the  instance  of  women  suffering  from  haemorrhoids,  the  diet 
should  be  carefully  regulated,  and  scrupulous  cleanliness  msisted  on  after 
stool;  mild  laxative  medicines  should  be  used,  and  such  cholagogues  as 
podophyllin,  iridin,  euonymin,  with  small  doses  of  a  mercurial  pill.  An 
aperient  water  such  as  Rubinat,  ^sculap,  Apenta,  or  Hunyadi  Janos  may  be 
given.  The  compound  powder  of  liquorice  is  a  useful  aperient  for  women. 
Also  this  mixtm'e  : — 

R     Ext.  cascara  liq.  ^i- 

Glycerine  ^i. 

Aq.  ad  3viii. 

The  elixir  of  saccharin  (^i.)  well  takes  the  i:)lace  of  the  glycerine — 5SS.  to 
be  taken  in  the  morning  early  or  at  bed-time. 

Cascara  bonbons  or  tabloids  are  efficient  modes  of  administering  cascara. 
The  syrup  of  figs  is  a  very  useful  aperient,  as  are  also  psyllium  seeds — one 
teaspoonful  of  which  can  be  taken  at  breakfast  or  the  midday  meal. 

Such  a  pill  as  the  following  will  generally  be  found  to  act  efficiently  : — 


986  DISEASES   OF    WOMEN. 

R     Pulv.  iridin        •>  ._  ^  3               Or,     R     Pulv.  euonymin,  gr.  i, 

Pulv.  euonymin/       ^  '  ^'                             Pil.  hydrarg.,  gr.  i. 

Hyd.  cum  cret.,  gr.  i.  Pil.  rhei  comp.,  gr.  ii. 

Ext.  col.  CO.,  gr.,  i.ss,  Ext.  nucis  vom.,  gr.  |-. 

Ipecacuanhse     ■>__  Ext.  hyoscyami,  gr.  ss. 

Ext.  hyoscyami/       *  '    "  Ft.  pil. 
Ft.  pil. 

Or,     R     Ext.  belladonnse,  gr.  J. 
Ext.  nucis  Tom.,  gr.  j. 
Pil,  rhoei  co.,  gr.  iii. 
Ext.  hyoscyami,  gr.  ss. 
Ft.  pil.     M. 

The  confections  of  sulphur,  senna,  and  black  pepper  are  useful  laxatives, 
especially  the  latter.     A  good  form  is  : — 

R     Tartr.  potassaj  acid.,  3ii. 
Pulv.  jalapse,  3i. 
Confect.  sulphuris,  ^i. 
,,         sennse,  ^i. 
,,         piperis  nigrse,  3ii. 
Mel.  opt.  ad  ^iv.     M. 
Ft.  confectio  ;  3i.  to  be  given  as  a  dose  at  night. 

The  glycerine  enema  (51.  of  glycerine  administered  with  the  glycerine  rectal 
syringe)  is  in  some  cases  an  efficient  means  of  emptying  the  rectum.  Its 
action  is,  however,  capricious,  and  is  occasionally  attended  by  severe  pain. 
The  suppository  of  glycerine  may  be  tried  instead  of  the  enema. 

Ointments  of  calomel,  with  bismuth,  cocaine,  and  belladonna ;  sol.  of 
subacetate  of  lead  ;  bismuth  with  glycerol  of  lead  ;  tannic  acid,  with  bismuth 
and  opium,  will  be  found  soothing  applications. 

In  cases  of  ulceration  of  the  rectum,  or  fissure,  ointments  of  bismuth  (siiss. 
of  carbonate  in  ^ii.),  calomel  (3ii.  in  ,^ii.),  morphia,  (gr.  iii.  ad  gr.  v.  ad  |ii.), 
belladonna  (gr.  xxx.  in  ^ii.),  pulv.  opii  (gr.  xx.  in  li.),  maybe  used  separately 
or  in  combination.     For  example,  a  most  useful  ointment  is  :— 

Bismuthi  trisnitratis,  3ii. 

Hydrarg.  subchlor.,  3ii. 

Ext.  belladonnse,  gr.  xv. 

Ext.  opii  liq.,  3ii. 

Lanolin,  ^ss.  . 

Aq.  rosse,  3i. 

Adeps  benzoatis,  ^ss.     M. 

For  application  with  the  rectal  positor  the  following  will  be  found  of  service : 
Cocaine,  both  in  the  form  of  ointment  and  lotion  for  the  rehef  of  pain. 
Eucaine  may  be  substituted  for  the  cocaine.  Iodoform  or  dermatol  can  be 
applied  internally  as  an  ointment,  or  dusted  externally  in  fine  powder  diluted 
with  starch.  In  syphilitic  cases  ointments  of  the  red  oxide  of  mercury,  iodide 
of  starch,  or  perchloride  of  mercury  are  most  useful.  The  odour  of  the 
iodoform  may  be  disguised  with  vanilline  or  coumarine.     The  '  lotio  nigra ' 


SOME  AFFECTIONS   OF   THE  RECTCM.  987 

of  the  pharmacopeia  with  hazeline  is  of  use  in  cases  of  ulceration  and 
syphilitic  condylomata. 

To  apply  an  ointment  to  the  rectum,  an  ointment  positor  is  required,  as 
otherwise  it  is  wiped  oft"  the  surface  of  the  finger  before  it  reaches  the  part. 
A  convenient  positor  is  that  shown  (Fig.  621).  The  ointment  is  contained 
in  a  tinfoil  tube,  and  the  pipe  is  of  soft  gum-elastic. 

Astringents.— Tannic  acid,  gallic  acid,  acetate  of  lead  in  ointments  ;  in- 
jections of  matico  and  oak-bark  ;  solutions  of  carbolic  acid,  chromic  acid, 
nitrate  of  silver.  Perhaps  the  best  local  astringent  in  cases  of  rectal  hajmor- 
rhage  is  the  sulphate  of  iron,  which  may  be  used  either  in  the  form  of 
ointment  (5ii.  ad  ^ss.),  suppository  (gr.  ii.  ad  gr.  x.),  or  as  the  liquor  ferri 
snlph.,  diluted  according  to  the  strength  required. 

Caustics. ^ — The  acids,  nitric,  carbolic,  and  chromic,  and  the  acid  nitrate  of 
mercury,  are  the  most  powerful  caustics  we  can  apply  both  to  ulcers  or 
bleeding  mucous  surfaces  ;  of  these  the  acid  nitrate  of  mercury  is  probably 
the  best.  The  surface  to  be  touched  should  be  carefully  exposed,  and  the 
acid  applied  with  cotton-wool  on  a  platinum  or  aluminium  wool-holder.     The 


Fig.  G21. — Eectal  Positok  of  Authuk. 

part  is  well  oiled  after  the  application.  "Where  the  actual  cautery  is  required, 
Paquehn's  mstrument  or  the  electro-cautery  are  commonly  used ;  the  former 
is  preferable  for  more  extensive  cauterization  and  the  latter  for  more  delicate 
use,  as  when  we  wish  to  cauterize  small  exposed  surface  fissures  or  ulcers. 

Coccygodyilia. — By  coccygodynia  we  understand  a  painful  afFec- 
tioa  of  the  coccyx  and  perineal  structures,  which  principally  shows 
itself  in  painful  sitting,  and  pain  in  the  act  of  defecation.  The 
structures  involved  are  :  the  coccyx,  the  sacro-coccygeal  ligaments, 
and  the  perineal  muscles  attached  to  the  coccyx. 

Causation. 

I  Blows,  kicks,  or  falls  on  the  coccyx. 
Difficult  parturition. 
Instrumental  delivery. 
Horse-exercise  (Scanzoni,  Goodell). 
Constant  sitting. 
Hysterical  temperament. 
Rheumatism. 

Uterine  and  ovarian  disease. 
Rectal  disease. 


DISEASES  OF   WOMEN. 


Severe  coccygodynia  may  be  present  in  an  unmarried  woman  in 
whom  not  one  of  the  causes  enumerated  above  can  be  traced. 

A  patient  some  time  pi'eviously  had  had  a  severe  attack  of  erysipelas  of  the 
face,  from  which  she  perfectly  recovered.  There  was  no  rectal,  uterine,  or 
other  local  trouble,  nor  was  she  in  the  least  of  an  hysterical  or  nervous 
temperament.  She  had  no  sedentary  occupation,  and  was  not  in  the  habit  of 
taking  horse-exercise.  At  first  her  sister  consulted  me,  telling  me  that  the 
patient  thought  she  suffered  from  internal  piles,  and  was  averse  to  seeking 
advice,  but  that  the  difficulty  in  sitting  had  become  so  great  that  she  could  not 
come  to  meals.  The  pain  had  come  on  gradually.  The  discomfort  produced 
by  examination  of  the  rectum  or  any  pressure  on  the  coccyx  was  inconsider- 
able, and  yet  she  could  not  sit  without  great  suffering.  In  this  case  relief 
was  afforded  by  sitz-baths,  counter-irritation  over  the  coccyx,  anodyne  lini- 
ments, and  suppositories,  a  rectal  plug,  which  was  woru  at  night,  and  the 
internal  administration  of  bromide  of  potassium  with  nux  vomica. 

Coccygodynia  may  be  the  most  troublesome  symptom  complained 
of  prior  to  mental  disturbance  showing  itself.  Such  instances  have 
come  under  the  author's  notice.  In  one  case  there  was  an  attempt 
at  suicide,  the  patient  attempting  to  drown  herself. 

On  examination  by  the  rectum  and  vagina,  the  coccyx,  if  dislo- 
cated or  fractured,  is  felt  quite  movable  or  loose. 

Treatment. — As  a  rule,  severe  coccygodynia  requires  operative 
measures,  but  first  such  nerve  tonics  as  arsenic,  strychnine,  sulphate 
of  zinc,  pyrophosphate  of  iron,  and  other  salts  of  iron,  if  there  be 
anaemia,  should  be  tried.  The  valerianate  of  zinc  and  the  ammoniated 
valerian  in  combination  with  the  bromide  salts  are  useful.  The 
painful  region  may  be  sprayed  with  ether  night  and  morning. 
The  application  of  the  actual  cautery  often  benefits.  Change  of  air 
and  scene,  suitable  exercise,  and  other  general  hygienic  measures, 
should  accompany  any  treatment.  If  palliative  treatment  should 
not  cure  the  patient,  the  subcutaneous  division  of  the  coccygeal 
ligamentous  and  muscular  attachments  may  be  proposed  (Sir  J. 
Simpson),  or  extirpation  of  the  bone  itself  can  be  carried  out  (Nott). 
In  deciding  on  any  radical  step,  such  as  subcutaneous  section  or 
removal,  we  are  influenced  chiefly  by  the  decision  as  to  the  traumatic 
character  of  the  affection.  It  is  in  those  cases  of  partial  dislocation 
or  other  injury  of  the  bone  that  extirpation  is  especially  indicated. 
The  important  practical  rule  to  adopt  in  any  case  in  which  we  are 
consulted  for  '  painful  sitting '  or  symptoms  of  coccygodynia  is  to 
exclude  carefully  any  uterine,  vaginal,  joerinseal,  or  anal  affection  which 
might  account  for  the  pain,  and  the  removal  of  which  will  often 
relieve  all  the  distressing  symptoms. 


SOME   AFFECTIONS   OF   THE   RECTUM.  989 

Operation. — This  should  be  carried  out  with  the  strictest  aseptic 
precautions.  An  incision  is  made  over  the  bone  in  the  middle  line. 
With  a  blunt-pointed  knife  it  is  severed  from  all  its  attachments, 
the  edge  of  the  knife  being  kept  close  to  the  bone.  It  is  then 
disarticulated  and  ablated.  The  wound  is  brought  together  with 
silver  or  gut  sutures,  and  covered  with  boric  lint  under  strapping 
and  a  T-bandage.     The  rectum  must  be  kept  quiet  for  a  few  days. 


CHAPTER   XLIX. 

STERILITY. 

It  is  not  possible  to  discuss  at  length  all  the  causes  which  in  a 
woman  result  in  sterility.  No  one  investigated  these  causes  with 
greater  minuteness  than  Marion  Sims.  Again  and  again  he  has 
examined  the  mucus  of  the  cervix  uteri  a  few  minutes  after  inter- 
course to  determiae  the  presence  or  state  of  the  spermatozoa  con- 
tained in  it,  or  the  quantity  of  seminal  fluid  retained  in  the  vagina. 
It  was  he  who  first  succeeded  in  impregnating  the  woman  by  the 
injection  of  semen  into  the  uterus,  though  the  patient  unfortunately 
miscarried  at  the  fourth  month  from  a  fall.  During  two  years  he 
made  as  many  as  fifty -five  uterine  injections  of  seminal  fluid. 

Artificial  fecundation  is  not  resorted  to,  so  far  as  I  know,  by  any  gynte- 
cologist  of  position  in  Great  Britain.  Within  recent  years  Mantegazza  has 
tabulated  the  conditions  in  which  such  intra-uterine  injections  of  seminal 
fluid  are  indicated. 

We  may  thus  summarize  the  most  important  facts  in  relation  to 
sterility  : — 

1.  In  order  for  conception  to  take  place  it  is  not  absolutely  necessary  for 
penetration  to  occur.* 

2.  The  spermatozoa  will  travel  a  considerable  distance  and  live  for  several 
hours  in  a  suitable  medium  and  at  a  proper  temperature. 

3.  It  is  necessary  that  the  seminal  fluid  should  contain  healthy  active  sper- 
matozoa, that  it  should  be  retained  in  the  vaginal  canal,  and,  if  possible,  that 
ejaculation  should  occur  in  the  axis  of  the  cervix  and  of  its  opening. 

4.  If  healthful  semen  be  deposited  in  the  vagina  within  a  few  days  before, 
and  within  ten  daj's  after,  a  menstrual  act,  conception  is  more  likely  to 
occur. 

To  complete  these  conditions,  we  require  a  sufficiently  long  vagina  with 
due  tonicity  of  its  walls,  and  the  uterus  as  nearly  as  possible  in  its  normal 
axis,;  the  uterine  and  vaginal  secretions  healthful,  and  contact,  at  the  right 
time,  of  the  ovum  with  the  spermatozoa. 

The  longest  period  that  I  have  known  marital  relations  to  have 
*  See  P13.  11,  12  on  the  Hymen. 


STERILITY. 


991 


continued  without  penetration  was  ten  years 
the  instance  of  a  highly 
intelligent  couple  in  good 
society.  The  lady  consulted 
me  for  pain  in  the  right 
side,  and  symptoms  of  ap- 
pendicitis. On  proceeding 
to  examine  the  ovary,  I 
found   a  thickened   hymen 

which  prevented  the  intro- 
duction of  the  linger.     On 

questioning    her    and    her 

husband,  I  found  that  there 

never  had  been  penetration. 

They  both  were  under  the 

impression  that  their  rela- 
tions were  natural.    I  made 

a    sketch   of   the    introitus 

before  ablating  the  hymen 

(Fig.  622).     The  hymeneal 

aperture  just   admitted    a 

dilator  of  a  circumference 

of  40  mm. 

I   subsequently  removed 


This  occurred  in 


Fig.  62:^. — lNTi:oiTUr^  ukawn  dkfmre  Abla- 
tion OF  THE  Hymen  in  a  Patient  ten 
Years  makkiep. 


a  large  cystic  ovary  and  a  distended  appendix. 

We  may  thus  classify  the  principal  causes  of  sterility  in  the 
female —  * 

1.  Absence  of  the  ovaries. 

„  „       Fallopian  tubes. 

„  „      uterus, 

„       vagina. 
Very  short  vagina. 
Congenital  ...  ^     2.  Atresia  of  the  Fallopian  tubes. 
„  „      uterus. 

,,  „      vagina. 

3.  Imperforate  hymen. 

4.  Conoidal  uterus,  stenosis  and  occlusion  of  the  os  uteri  or 

cervix. 

*  See  especially  the  chapters  bearing  on  dysmenorrhcea.  dilatatiun  of  the 
cer«s,  stenosis  of  the  cervix,  congenital  malformations,  gonorrhrea.  and  vaginis- 
mus. It  is  very  doubtful  how  far.  in  a  woman  capable  of  procreation,  mere 
contraction  of  the  lumen  of  the  uterine  canal  is  to  be  regarded  as  a  cause  of 
sterility — probably  very  seldom. 


992 


DISEASES  OF   WOMEN. 


f  1.  Strictured  states  of  the  Fallopian  tubes. 
,,  „  uterus. 

,,  ,,  vagina. 

2.  Tumours  obstructing  the  Fallopian  tubes. 

,,  „  uterus. 

„  vagina. 

,,  ,,  vulva. 

3.  Displacements  of  the  Fallopian  tubes. 

,,  ,,  uterus. 

4.  Inflammatory    states    of    the    genital  tract — especially 

chronic  endometritis. 

5.  Chronic  metritis. 

6.  Disease  of  the  ovaries. 

7.  Ovarian  dysmenorrhoea. 

8.  Membranous  d^'smenorrhoea. 

9.  Menorrhagia. 

10.  Dyspareunia — painful  intercourse  from  any  cause. 

11.  Vaginitis  and  vaginismus. 

12.  Gonorrhcea  and  its  consequences. 

13.  Syphilis  (in  the  sense  that  it  destroys  the  vitality  of  the 

ovura). 


Acquired 


The  reader  will  refer  to  the  chapters  in  which  each  of  the  above- 
mentioned  causes  of  sterility  in  the  woman  is  discussed. 


Sterility  due  to  Defect  in  the  Male. 

As  we  are  very  frequently  consulted  for  sterility,  the  possibility 
of  the  cause  resting  with  the  husband,  and  not  with  the  woman, 
has  to  be  remembered.  The  fact  that  many  women  who  are 
barren  with  one  husband  are  fertile  with  another  is  not  to  be  over- 
looked. 

Sterility  in  the  male  depends  on  more  than  want  of  a  healthy 
erection.  The  seminal  fluid  must  contain  virile  spermatozoa. 
Therefore  a  man  may  not  be  impotent  and  yet  be  sterile.  Strong 
sexual  desire  and  power  may  thus  be,  as  Curling  has  shown,  co- 
existent with  sterility,  and,  through  the  absence  of  conception,  may 
be  the  cause  of  serious  affections  of  the  sexual  organs  in  women. 
Thus  a  clear  distinction  has  to  be  kept  in  mind  between  the  terms 
'  sterility  '  and  '  impotence.'  Those  inhibitory  forces  which  over- 
come the  reflex  excitation  in  the  sexual  centre,  and  thus  iidiibit 
the  normal  process  of  erection  in  the  male,  must  be  remembered 
in  the  treatment  of  male  impotence.  It  is  a  matter  of  common 
observation  that  the  cerebral  impulses  are  often  blunted  or  arrested 
by  excessive  mental  strain,  and  are  held   in  check  by  healthful  and 


I^TERILTTT. 


993 


continuous  brain  work.  Thiis  relation  of  cerebral  control  to  erection 
and  seminal  discharge  is  shown  physiologically  in  the  case  of  spinal 
injuries,  cerebral  concussion,  and  the  seminal  emissions  which  result 
from  hanging.     Cerebral  inhibitory  control  is  lost. 

Clearly,  then,  the  virile  powers  and  health  of  the  husband  have 
to  be  inquired  into  when  we  are  consulted  by  a  woman  as  to  the 
cause  of  her  sterility.  It  must  also  be  remembered  that  the  general 
health  in  both  sexes  has  a  potent  influence  on  fecundity. 

Gross  has  estimated  that  one  male  in  every  six  is  sterile.  This  is  probaljly 
too  high  an  estimate.  It  is  certainly  much  higher  than  the  estimated  sterility 
of  women.  There  may  be  incomj^atibilitT/  of  the  sexes,  and  sterilitj'^  as  a 
result,  thougli  neither  the  man  nor  the  woman  is  sterile,  for  either  separately 
may  he  fertile  to  another  person,  and  procreate. 

Certain  points  have  to  be  carefully  inquired  into  of  the  husband — 
(1)  Are  there  healthy  erections?  (2)  Are  there  nocturnal  emissions? 
(3)  Is  semen  ejaculated  during  intercourse  ?  (4)  Does  emission  occur  pre- 
maturely, or  is  there  incomplete  coitus?  (5)  Is  there  sensation?  (6) 
Is  there  pain  in  the  penis  with  intercourse  ?  (7)  Is  there  any  affection  of 
the  prostatic  urethra  or  prostate  gland  ?  (8)  Does  he  masturbate  ?  (9)  Is 
there  stricture  of  the  urethra  in  any  part  ?  (10)  Is  the  foreskin  tight  in 
erection  ? 

It  may  be  well  to  suramai'ize  the  causes  of  sterility  and  impotence 
in  the  male. 

Impotence. — Gross  subdivides  the  causes  of  inipotence  under  four  heads  : 
Atonic,  PsycMcal,  Symptomatic,  Organic.  We  may  further  briefly  classify 
(following  this  authority)  the  causes  of  impotence  thus — 

Muscular  paresis  both  in  the  walls  of  the  vessels  and  in  the 
muscular   trabeculae   and  the   perineal   muscles,   brought 
I      about  by 
I  Masturbation      '\ 

or  >causing  exhaustion  of  tlie  lumbar  centre. 

Venereal  excess  J 
/  r Ineffectual  erection  and  ejaculation. 

I  Sexual  desire  present  <  Premature  emission. 
I  (.Incomplete  intercourse. 

Sexual  desire  absent — Loss  of  erectile  power. 
/"Loss  of  sexual  power  from  a  prolonged  or  excessive  use  of 
I      bromide  salts,  iodine  and  iodide  salts,  camphor,  conium, 
j      opium,  morphia  (in  lead-poisoning),  alcoholism,  antimony 
I     fumes. 


Atonic 


Symptomatic 


Organic — 

Azoaspermia — absence  of 
spermatozoa   ... 


The  fault  may  be  due  to  absent,  retained,  unde- 
veloped, diseased  testicles ;  obstruction  in  the 
epididymis  and  vas  deferens,  or  injury  to  the 
latter  during  operations ;  disease  of  the  same 
parts,  possibly  due  to  past  gonorrhoea  or  syphilis. 

3  s 


994 


DISEASES   OF   WOMEN. 


Aspermia  —  want  of 
ejaculation  of  semen 
daring  coitus 


Organic-obstructive 


'  Organic  obstruction — ejaculatory  ducts  or  urethra. 
Atonic — want  of  excitability  in   the    ejaculatory 

I      centre. 

j  Anaesthetic — loss  of  sensibility  in  the  nerves  of  the 
penis. 

\  Psychical — cerebral  inhibition. 

'Absence  of  the  penis  or  other  abnormalities,  in- 
cluding hypospadias  and  epispadias;  curvature 
of  the  penis,  the  result  either  of  congenital 
defects,  wounds,  or  gi'owths  in  one  or  both  of 
the  cori:)ora  cavernosa,  varix  of  the  dorsal  vein, 
tight  prepuce,  short  frsenum,  retained  testes, 
atrophic  testicles  produced  by  any  cause,  syphi- 
litic and  tubercular  orchitis. 
May  be  due  to  congenital  defects,  stricture  in  the 
ejaculatory  ducts  and  urethra,  stenosis  in  the 
ejaculatorj^  ducts,  spasm  of  the  urethra. 

rWant  of  coutractile  power  in  the  seminal  vesicles, 

I      ejaculatory  ducts,  urethral  muscles  ;  incomplete 

1      coitus  results — the  act  is  abandoned  from  loss  of 

[     strength. 

I  Insensibility  in  glans,  jjrostatic  sinus,  or  prostatic 

I     urethra. 

(  During  phthisis,  Bright's  disease,  spinal  cuiTature, 

!      degeneration  of  the  cord,  spinal  injuries,  after 

(.     the  zymotic  fevers. 

(This  head  includes  any  variety  of  mental  deterrent 
influence,   such   as   nervous   apprehension,    re- 
. morse,  physical  repulsion,  want  of  afiBnity,  and 
other  purely  psychical  causes.     This  class  in- 
j      eludes  generally  all  those  imaginative  victims  of 

advertising  quacks. 
I  There    may   be    inhibitory   restraint    voluntarily 
\     exercised  during  coitus.* 

Many  cases  are  curable  by  proper  treatment  and  judicious  advice 
to  both  husband  and  wife.  At  times  every  effort  to  bring  about 
the  desired  result  fails.  Such  cases  constantly  come  before  the 
gynaecologist,  for  there  is  no  doubt  that,  in  addition  to  the  un- 
happiness  caused,  they  are  the  frequent  sources  of  morbid  states  of 
the  uterus  and  adnexa.  Hypersesthesia  of  the  vulva,  vaginitis, 
erosion  of  the  cervix  uteri,  ovaritis,  or  salpingitis,  are  their  not 
uncommon  accompaniments. 

At  times  steriHty  is  traceable  to  both  male  .and  female  sexual   defects. 


Atonic 


Anaesthetic 


Symptomatic 


Psychical 


*  The  reader  will  find  an  admirable  summary  of  the  entire  subject  in  Jacob- 
son's  work  on  '  Diseases  of  the  Male  Organs  of  CTcneration.' 


S!TElif/./Ty.  'J95 


A  lady  had  beou  married  for  five  years.  There  had  been  no  intercourse 
for  a  considerable  time  after  marriage.  The  husband  suffered  from  atonic 
and  ijsychical  aspermia.  Of  this  he  was,  after  some  difficulty,  cured  by  the 
late  Hack  Take,  to  whom  I  was  indebted  for  the  case.  The  wife  sulfered 
from  dysmenoniioea.  On  examination  I  found  a  typical  conical-shaped 
cervix  and  a  minute  uterine  orifice.  She  had  the  internal  cervix  divided. 
The  canal  was  with  dilhculty  kejit  patent.  She  went  through  a  course  of 
internal  faradization  for  the  dysmenorrhoea,  of  which  she  was  cured.  But 
conception  did  not  occur  for  a  length  of  time,  though  the  canal  of  the 
uterus  remained  permanently  dilated.  She  finally  conceived  and  bore  a 
healthy  child. 

One  caution  I  think  it  well  to  give.  The  surgeon  is  not  to  be 
led  away  by  the  miraculous  cures  of  sterility  he  hears  of,  or  the 
occasional  success  he  may  himself  meet  with  in  rectifying  some 
obstruction  to  impregnation,  to  perform  liurriedly  operations  on 
the  uterus  with  a  view  of  '  curing  sterility.'  Failure  will  attend 
a  lai'ge  proportion  of  such  operations.  The  patient  should  be 
frankly  pi-epared  for  this.  Also,  these  uterine  operations  are  not 
devoid  of  some  slight  degree  of  risk,  and  barrenness  has  all  its 
evils  aggravated  when  the  miserable  hypochondriac  becomes  the 
victim  of  delusive  hopes  and  disappointing  operations.  AVhen 
some  diseased  or  abnormal  condition  of  the  uterus  exists  which  it 
is  our  duty  to  treat  by  operation,  and  the  cure  of  which  may  bring 
about  a  possibility  of  impregnation,  it  is  right  to  interfere.  I 
do  not  mean  to  deprecate  any  justifiable  and  judicious  interference 
with  an  otherwise  healthful  woman  who  happens  to  be  barren,  in 
order  to  bring  about  conception.  The  surgeon,  however,  cannot 
divest  himself  of  responsibility  if  there  follow,  either  directly  from 
the  operation  or  indirectly  from  the  results,  dangerous  or  j^er- 
manently  serious  consequences,  even  though  she  and  her  husband 
may  accept  any  risk  entailed. 


Congenital  Absence  of  Uterus  and  Adnexa  and  Rudimentary 
Mammary  Glands. 

It  has  to  be  remembered  that  the  external  genital  organs  may  be  perfect, 
and  yet  there  may  be  absence  of  the  ovaries  and  oviducts  as  well  as  the  uterus. 
Such  a  case  I  lately  saw.  The  patient  was  twenty-two  years  old.  She  had 
never  menstruated,  and  had  tried  various  remedies  from  tinae  to  time  for  the 
absence  of  the  catamenia.  She  had  never  been  examined  by  the  vagina. 
The  uterus  was  absent,  a  small  body  about  the  size  of  a  marble  representing 
it.  There  were  no  adnexa.  Rudimentary  nipples  were  present,  and  only 
the  vestige  of  mammary  glands. 


996  DISEASES  OF   ^Y02IEX. 

Sterility  and  Fecundity. — George  Engelmann  *  investigated  the 
causes  c&  the  increasing  sterility  of  American  women,  and  showed 
that  some  20  per  cent,  and  over  of  married  women  were  childless — a 
great  increase  from  the  earlier  days  of  the  century,  when  the  per- 
centage was  only  2  per  cent.,  or  even  on  that  calculated  by  Simpson, 
at  11  per  cent.  The  high  rate  of  sterility  and  the  low  fecundity 
in  the  United  States,  according  to  Engelmann,  are  worse  than  in 
any  other  country  save  France,  and,  for  native  Americans,  worse 
than  France.  Engelmann  considered  a  woman  stei'ile  who  had 
been  married  three  years  without  giving  birth  to  a  full-term 
child  ;  absolute  sterility  meant  that  she  had  never  conceived ;  relative 
sterility  involved  conception  and  miscarriage,  no  full-term  child 
having  been  given  birth  to.  While  the  rates  in  America  and 
Canada  vary  according  to  race,  reaching  in  some  places  as  high  as 
27  per  cent.,  and  in  the  case  of  university  graduates  to  over  30  per 
cent.,  the  rate  in  Norway  is  as  low  as  2-5  per  cent.  Luxury  and 
wealth  go  imri  passu  with  high  sterility,  and  the  influence  of  higher 
education  appears  to  affect  English  women  as  deleteriously  as  their 
American  sisters,  for  among  the  collegiate  classes  in  England  it 
reaches  as  high  as  27*6  per  cent.  The  number  of  women  who  from 
any  cause  have  never  conceived  is  greater  than  that  of  those  who 
have  miscarried  but  have  not  borne  a  living  child.  The  former 
amount  to  some  8  per  cent,  of  all  married  women,  and  Engelmann 
puts  the  rate  of  the  absolutely  sterile  as  high  as  12  per  cent,  among 
Americans,  while  he  found  the  ratio  of  miscarriages  to  labours  at 
term  to  be,  not  1  to  o'l  as  usually  accepted,  but  1  to  2-8  to  3-03. 
The  highest  fecundity  among  American-born  women  does  not, 
according  to  Engelmann,  exceed  2-1  to  each  marriage,  in  some 
places  being  only  1"7.  One  important  point  is  shown  clearly  by 
various  investigators,  viz.  that  over-pressure  in  scholastic  training 
and  university  work  have  a  marked  deteriorating  influence  on 
fecundity.  In  England  among  female  college  graduates  there  are 
only  1"53  children  to  each  marriage,  the  average  fertility  of  other 
English  women  being  over  four  children  to  each  marriage.  The 
earlier  ratio  in  America  would  appear  to  have  been  from  five  to 
eight  children  to  each  marriage. 

Engelmami's  investigations  would  also  appear  to  prove  that  there 

is  a  correlation  between  the  prevalence  of  divorce  and  sterility  or 

low  fecundity  in  those   States  where  divorce  is  common.     On  the 

whole,  then,    it  would  seem  that  highly  developed  mental  culture 

*  Jour.  Ainer.  Med.  As.^..  Oct.  .^,  1901. 


FlTETtfrjrY.  OiC/ 


and  luxurious  living  promote  sterility  and  lessen  fecundity.  As 
has  been  already  stated,  sterility  has  to  be  looked  at  from  the  male 
side  as  well  as  the  female.  It  is  difficult  to  arrive  at  a  conclusion, 
as  to  the  relative  number  of  sterile  men  to  sterile  marriages.  Gross 
placed  it  at  16  per  cent. ;  Brothers  at  one  sterile  man  in  every  five 
childless  marriages.  Engelraann  inclines  to  a  higher  rate.  If  we 
regard  the  normal  proportion  of  barren  marriages  at  2^^^^  per  cent., 
it  is  apparent  how  far  from  this  standard  we  have  gravitated,  nob 
only  in  America,  but  in  many  European  countries.  The  French 
Canadians  would  appear  to  have  the  highest  standard,  the  number 
of  children  to  each  marriage  reaching  as  high  as  nine. 

In  a  most  interesting  address  on  '  The  Diiuiuisbing  Birthrate  and  what  is 
involved  by  it,'  *  John  Taylor  dealt  with  this  entire  subject  before  the 
British  Gyneecological  Society.  He  there  showed  statistically  that  the 
physical  and  psychical  potentialities  and  attributes  of  children  born  from 
comparatively  infertile  marriages  bave  deteriorated,  and,  as  a  consequence, 
that  the  forces  tending  to  criminality  are  on  the  increase,  inasmuch  as  it  is  in 
the  liigber  and  middle  classes  that  the  diminishing  birthrate  is  especiallj' 
noticeable.  In  the  same  paper  be  traced  the  relation  between  the  preventive 
measures  so  largely  resorted  to  in  France  and  other  countries  to  this 
diminishing  birthrate,  and  the  general  decadence  and  demoralization  of  the 
population. 

Treatment. — With  reference  to  the  treatment  of  sterility,  it  is 
obvious  from  what  has  been  stated  here,  as  well  as  in  those  chapters 
in  which  congenital  abnormalities  of  the  female  genitalia  have  been 
dealt  with,  that  the  first  step  must  be  to  make  a  careful  inquiry 
into  the  condition  of  the  external  and  internal  genitalia  of  the 
woman.  The  introitus  should  be  examined,  so  as  to  ascertain  its 
patency  and  sensitiveness.  The  nature  of  the  act  of  coitus, 
whether  painful  or  otherwise,  must  also  be  inquired  into.  Should 
dyspareunia  be  present,  its  cause  should  be  determined,  whether  it 
be  in  the  A'agina  and  due  to  vaginismus  or  vaginitis,  or  following 
on  some  sensitiveness  in  the  adnexa  and  uterus.  Congenital  atresic 
states  of  the  vulva  and  vagina  will,  of  course,  when  present,  im- 
mediately explain  the  sterility,  as  also  will  stenosis  of  the  uterine 
canal,  when  the  typical  abnormality  of  the  portio  is  present  with 
the  small  external  opening.  The  adnexa  must  also  be  examined, 
lest  they  be  absent.  In  other  cases  tumours  may  be  discovered 
which  are  the  cause  of  an  obstruction.  Where  there  is  severe 
dysmenorrhcea  attending  upon  dyspareunia,  the  condition  of  the  tubes 

*   Brit.  Gyu.Jour..Mny,  11)04, 


998  DISEASES   OF    WOMEN. 

and  ovaries  must  be  ascertained.  Should  there  be  inflammatory 
states  of  the  endometrium  with  bloctage  of  the  uterine  canal, 
this  will  call  for  the  treatment  which  has  been  laid  down.  On 
many  occasions,  dilatation  of  the  uterine  canal  and  free  curet- 
tage I  have  found  were  followed  by  early  conception,  and  it  is  a 
matter  of  common  knowledge  that  ordinary  dilatation,  proper  pre- 
cautions being  taken  as  to  the  time  at  which  it  is  done,  is  often 
followed  by  conception.  The  time,  with  regard  to  the  catamenial 
period,  at  which  conception  is  most  likely  to  follow,  should  be 
indicated,  excessive  intercourse  prohibited,  and  its  complete  avoid- 
ance for  a  short  period  advised. 

Should  there  be  no  obvious  proof  after  examination  of  the  woman 
that  the  reason  rests  with  her,  the  husband  should  be  interviewed, 
and  the  source  of  any  probable  cause  of  impotence  on  his  part 
investigated. 


CHAPTER   L. 

GYNECOLOGICAL    ELECTRO-THERAPEUTICS.* 

Apostoli's  Methods. — Cutter  practised,  and  urged  the  value  of, 
the  electrical  treatoaent  in  various  uterine  affections.  Apostoli 
acknowledged  his  indebtedness  to  A.  Tripier,  who  '  devoted  thirty 
years  in  a  glorious  scientific  struggle  to  seek  a  panacea  for  metritis 
in  the  induced  current  of  quantity.'  As  far  back  as  1873  Routh 
and  Althaus  used  continuous  currents  of  high  intensity  in  the 
treatment  of  uterine  fibroids.  Apostoli  aimed  at  supplanting  the 
old  way  of  operating  by  a  method  more  'precise,'  'energetic,' 
'tolerable,'  'better  localized,'  'more  thoroughly  under  control,'  and 
'  scientifically  exact.' 

Obviously  an  elementary  knowledge  of  the  laws  of  electrical 
forces  must  be  assumed,  and  some  acquaintance  with  the  modes  of 
action,  physical,  chemical,  and  therapeutical,  of  the  different  kinds 
of  electricity  on  the  human  body  is  essential  before  resorting  to 
this  method  of  treatment. 

It  may  be  truthfully  stated  that  the  gal vano -caustic  method  of 
treatment  of  myomata  of  the  uterus,  or  tumours  of  the  adnexa, 
has  taken  no  hold  in  this  country,  nor,  indeed,  abroad.  The 
same  may  be  said  of  the  method  of  galvano-puncture,  either  in 
vaginal  fluctuating  tumours,  or  in  myomata  of  the  uterus.  The 
uncertainty  of  the  results,  the  technical  difficulties  connected  with 
their  safe  and  efficient  performance,  the  acknowledged  risks  attendant 
upon  them,  have  all  contributed  to  influence  the  minds  of  surgeons 
unfavourably  with  regard  to  these  electrical  methods  generally,  as 
compared  with  the  more  certain,  safer,  more  expeditious,  and  suc- 
cessful operative  measures  by  means  of  the  ordinary  surgical  pro- 
cedures. There  can  be  no  doubt  that  in  many  cases  faradization 
does  give  relief  in  dysmenorrhcea,  subinvolution,  and  painful  affections 
of  the  ovary.  As  the  most  perfect  instructions  for  the  carrying 
out  of  faradization  are  those  of  Apostoli,  I  briefly  summarize  here 
directions  for  the  application  of  the  faradic  current. 

*  For  electro-thermocausis  in  the  removal  of  tumours,  etc.,  see  p.  502. 


1000  DISEASES   OF    WOMEN. 

With  regard  to  the  galvano-caustic  treatment,  in  previous  editions  the 

more  minute  details  of  Apostoli's  methods  have  been  described.  No  one 
should  resort  to  them  who  has  not  mastered  these  details  and  taken  all  the 
precautions,  before,  during,  and  after  operation,  enforced  by  Apostoli  him- 
self. These  include  careful  preliminary  examination,  attention  to  the 
temperament  of  the  patient — if  neurotic  or  hysterical  (contra-indicating 
conditions),  the  most  exhaustive  inquiry  into  the  pre^^ous  clinical  history  of 
the  woman,  and  any  associated  pathological  states,  the  minutest  care  as  to 
the  place  and  its  surroundings  in  which  the  treatment  is  carried  out,  the 
time  of  the  menstrual  epoch,  abstinence  from  cohabitation,  the  most  com- 
plete asepsis.  If  it  be  true  that  the  most  experienced  of  us  are  liable  to  err, 
that  our  greatest  gynaecologists  have  placed  on  record  errors  both  avoidable 
and  unavoidable,  and  that  Apostoli  himself  tells  of  his  '  not  recognizing  a 
suppurating  ovarian  cyst  which  ended  in  death  from  peritonitis,'  how  careful 
must  the  surgeon  be  to  make  assurance  doubly  sure  before  he  resorts  to 
electrolysis,  and  decides  on  the  extent  to  wliich  he  will  avail  himself  of  it,  or 
the  exact  mode  in  which  he  will  apply  it  ! 

None  who  carefully  read  Apostoli's  review  of  his  own  work,  of  his  acknow- 
ledgment of  '  blunders '  made  in  carrying  out  the  treatment,  of  the  cautions 
he  gives  as  to  exactitude  of  dose,  antiseptic  precautions,  and  all  the  other 
details  of  operations,  the  performance  of  which  demands  that  the  operator  be 
'  both  gynpecologist  and  electrician,'  will  refuse  to  admit  that  the  risks  to  the 
patient  are  in  inverse  ratio  to  the  experience  of  the  operatoi*.  Therefore  the 
surgeon  must  err  on  the  side  of  excess  of  caution,  and  surround  his  patient 
with  every  possible  safeguard  both  before,  during,  and  after  operation,  in 
careful  antisepsis,  in  regulating  the  strength,  character,  and  extent  of  the 
electric  application,  as  well  as  the  length  of  time  it  is  applied,  and  in  estimat- 
ing the  tolerance  of  the  patient  and  her  special  susceptibihties  to  electrical 
influences.  Something  else  of  still  greater  importance  is  demanded  of  the 
operator,  without  securing  which  all  these  safeguards  may  be  valueless, 
namely,  an  accurate  diagnosis.  I  had  in  one  case  of  xaj  own  clear  e^'idence 
that,  even  when  surrounded  with  every  conceivable  precaution,  this  method 
of  treatment  is  not  devoid  of  danger,  and  that  death  may  occur,  whether  due 
directly  to  the  operative  procedure  itself,  or  indirectly  to  it  and  unpropitious 
conditions  in  the  patient.  In  the  instance  I  refer  to,  the  patient  was  a 
woman  of  a  nervous  temperament,  manifested  at  times  by  attacks  of  a 
hystero-cataleptic  nature.  These  nervous  attacks  were  precipitated  by 
violent  uterine  lisemorrhages,  and  were  attended  with  the  most  severe  flatulent 
eructations  I  have  ever  heard.  Great  success  ^vith  any  operative  procedure, 
even  in  hands  the  most  endowed  by  nature  with  manipulative  dexterity,  and 
guided  by  the  clearest  intellect,  can  only  be  attained  with  an  experience  in 
which  some  failures  or  blunders  have  taught  the  lessons  which  have  ensured 
the  ultimate  approach  to  perfection.  As  characteristic  of  the  different 
opinions  on  the  value  of  the  method  of  ApostoH,  we  may  quote  the  following 
views  of  Rokitansky,  A.  Martin,  and  Mackenrodt : — 

Eokitansky  in  Vienna  *  reported  results  of  cases  treated  during  two  and  a 
half  years.    There  were  twenty-two  fibromata  of  the  uterus,  one  of  perimetric 

*  Wiener-Min.  Wclms.,  1890,  Nos.  i~  and  48. 


GYNMCDLOGTCAL    ELECTRO-'rHERAPEUTTCS.  1001 


exudation,  and  eighteen  cases  of  the  various  forms  of  chronic  endometritis. 
The  total  number  of  sittings  amounted  to  about  GoO.  Tlie  greatest  number 
of  sittings  that  any  one  patient  was  subjected  to  was  sixty-three.  Their 
duration  varied  between  five  and  ten  minutes  (in  two  cases  twelve  minutes). 
The  intensity  of  the  current  seldom  exceeded  100  to  110  (once  it  reached 
300)  milliamperes.  This  plan  of  treatment,  he  says,  is  occasionally  valuable, 
but  even  when  used  correctly  and  witli  care  it  has  its  dangers,  is  painful, 
slow,  and  does  not  always  produce  the  desired  results,  and  is  often  only  a 
palliative  measure. 

A.  Martin  and  Mackenrodt  *  treated  sixty-six  cases  of  uterine  myomata. 
In  the  first  group  (55'5  per  cent.),  for  the  most  part  with  small  tumours,  the 
results  were  favourable,  in  so  far  as  haemorrhage  and  pain  were  lessened  and 
the  general  condition  was  improved.     On  the  other  hand — 

1.  There  was  no  case  in  which  the  tumour  disappeared : 

2.  Nor  was  the  size  of  the  tumours  diminished,  beyond  all  doubt. 

3.  In  twenty  of  the  thirty-six  cases  the  menopause  occurred  during  the 
treatment,  with  regi'essive  changes  in  the  tumours. 

4.  In  twelve  the  improvement  was  not  entirely  permanent. 

5.  In  44*5  per  cent,  there  was  no  improvement  at  all ;  the  condition  of  the 
patients  grew  worse,  and  three  cases,  8'3  per  cent.,  died  during  treatment. 

On  the  ground  of  their  experience  and  that  of  others,  the  above  authors 
reject  the  Apostoli  treatment  of  myomata. 

Analyzing  some  statistics  of  Keith  and  Schafter,  they  found  that  of  212 
cases,  in  32  per  cent,  the  sj^mptoms  were  relieved:  in  44  per  cent,  they 
became  worse,  and  nine  patients  ^4*3  per  cent.)  died.  In  no  instance  did 
the  tumour  disappear.  Moreover,  the  so-called  '  symptomatic  cure '  was 
only  permanent  when  the  patient  was  near  the  menopause  at  the  time  of 
the  treatment :  before  this  period  the  h?emorrhage  frequently  recuired. 

Granting  that  electricity  is  a  palliative  means  of  treating  fibroids, 
it  remains  to  inquire  why  the  results  are  so  variable.  Now  that 
the  various  degenerative  changes  that  occur  in  myomata  are  better 
understood  and  recognized,  it  becomes  all  the  clearer  why  this 
treatment  cannot,  in  certain  cases,  be  beneficial,  nor  indeed  safe  to 
employ.  Also  there  is  the  difliculty  in  carrying  it  out,  the  loss  of 
time  and  the  discomfort — no  small  considerations  wdth  the  great 
majority  of  cases  that  we  are  called  upon  to  treat. 

Indications  for  Faradization. 
The  following  indications  are  laid  down  by  Apostoli : — 

Low-tension  Current  (primary  helix  and  thick  wire  bobbin). 
Arrested  involution  and  secondary  post-partum  haemorrhage. 
Subinvolution. 
The  acute  stages  of  perimeti'itis  and  ovaritis. 

*  DeuU.  Me<1.  Wchns.,  Xo.  2.  1892. 


1002 


DISEASES   OF   WOMEN. 


Low-tension  Current  (primary  helix  and  thick  wire  bobbin)  (continued) — 
Chronic  metritis. 
Menorrhagia. 
Amenonhoea. 
Dysmenorrhoea. 

High-tension  Current  (thin  and  long  wire  bobbin). 
Vaginismus. 
Oophoralgia. 

If  a  current  of  quantity  be  required,  as  in  cases  of  amenorrhcea  or  ha3raor- 
rhage  arising  from  arrested  involution,  the  thick  wire  bobbin  is  used.  If,  on 
the  other  hand,  the  current  of  tension  be  indicated,  as  in  the  pain  of  oopho- 
ralgia, dysmenorrhcea,  and  in  salpingo-ovaritis,  the  thin  and  long  wire  bobbin 
is  used. 

1,  Commence  with  the  simple  vaginal  application,  using  a  long  bipolar 

electrode. 

2.  Let  the  current  be  very  mild 
in  the  first  application.  Avoid 
the  infliction  of  any  shock,  and 
be  most  careful  of  any  sudden 
jerking  motion  of  the  bobbin. 

3.  Carefully  judge  by  the  coun- 
tenance and  expression  ;  by  ques- 
tioning the  patient  of  her  toler- 
ance of  the  current. 

4.  Apply  the  '  vaginismus '  elec- 
trode to  the  most  painful  spot  in 
the  vaginal  roof,  and  the  '  con- 
centric carbon '  uterine  electrode 
to  the  cervix  uteri. 

5.  After  a  few  such  sittings  (if 
indicated)  apply  one  of  the  bipolar 
intra-uterine  sounds,  with  the 
same  extreme  care  to  avoid  the 
infliction  of  shock,  and  to  cause 
only  such  pain  as  is  easily  borne 
hy  the  patient. 

6.  One  sitting  daily  will,  as  a 
rule,  be  sufficient.  This  should 
last  from  five  to  twenty  minutes, 
its  length  being  regulated  by  the 
effect  produced. 

7.  The  bipolar  sound  should  not  be  introduced  into  the  uterus  during  the 
progress  of  any  acute  inflammatory  affection  of  the  uterus,  ovary,  or 
Fallopian  tube. 


Fig.  623. — Showing  the  Electrode  in 
THE  Uteeine  Caa-itt.    (Bigelow.) 


a  YXJECOLOGICAL    ELECmn-  THE  HA  I'/Cl'TrCS. 


1003 


Appliances  required  for  the  Faradic  Treatment. 

Battery. — A  battery  is  required  whicli  sliall  yield  botli  low  and  high  tension 
currents,  capable  of  being  increased  without  anj''  sudden  jerks,  so  as  to  avoid 
the  infliction  of  shocks.  For 
this  purpose  the  sledge -coil  is 
the  best.  High-tension  bobbins 
of  very  thin  wire  slide  over  the 
low-tension    bobbins   of   thick 


Such  a  battery  as  that  shown 
at  Fig.  G24  (Coxeter)  will  be 
found  to  answer  the  purpose 
admirablj'.  There  are  two  bob- 
bins of  different  thickness  of 
wire,  and  thus  a  current  of 
medium  or  high  tension  can  be 
obtained.  The  terminals  needed 
are  : 

Bipolar  intra-uterine  exciters  (two  sizes). 
A  concentric  bipolar  electrode,  for  application  to  the  uterus, 
A  bipolar  vaginal  electrode.     The  insulating  substance  is  placed  hori- 
zontally between  the  metal  terminals,  these  latter  being  at  some  distance 
from  each  other. 
A   bipolar   (vaginismus)    vaginal   electrode.        The    insulating   substance 
dividing  the  electrode  into  two  is  very  thin,  and  is  placed  vertically, 
and  the  poles  are  thus  carried  to  the  end  of  the  electrode,  so  that  it 
can  be  applied  to  any  painful,  sensitive,  or  neuralgic  spot.     All  these 


Fig.  *!24. — Fakadic  Current  Battery. 


m  — P 


Figs.  G2,i,  G2G.— Bipolar  Ixtra-uterixe  Exciter,  of  two  Sizes. 


Fig.  627. — Concentric  Bipolar. 


1004 


DISEASES   OF   WOMEN. 


terminals  are  insulated,  so  as  to  avoid  any  accidental  shock  to  the 
administrator. 


1 


fH)!^ 


Fig.  628. — Bipolae  Vagina 


y^m^ 


Fig.  629. — Bipolar  Vaginal. 

Galvano-caustic  Method. 

The  appliances  required  for  the  galvano-caustic  treatment  and  the  galvanic 
cantery  are  : 

A  sulphate  of  mercury  battery,  twenty-four  cell.«,  with  double  collector,  by 
means  of  which  each  cell  can  be  tested  separately.  This  battery  remains  in 
action  so  long  as  the  fluid  is  kept  in  contact  with  the  elements. 

G-as-carbon  Sounds  of  Apostoli. 

The  object  of  these  sounds  is  to  enable  the  operator  gradually  to  increase 


o   o 


DC 


'^      ^ 


G  E 

Ftg.  630, — Electrode  for  Galvano-chemical  Cauterization 


(one-third  actual  size). 


Fig.  632. — Platinhm-enped  Soinds  with  Fli-xible  Stems. 


GYNJECOI.OmCAL   1<:LK(TI;(i-TII  E  H  M'K  r'JlCF!.  KiOf) 

the  size  of  the  gas-oarbou  terminals,  so  as  to  arrive  at  a  periect  co-aptation  of 
the  electrode  to  the  uterine  cavity.     The  electrode  consists  of : 
(M)  Handle  for  attachment  of  rheopliore. 
(E)  Caoutchouc  covering  of  the  metallic  stem,  which  is  marked  liy  circular 

grooves  at  regular  distances  of  2i  centinietrcs. 
(C)  Gas-carbon  terminal  2},  centimetres  long.     This,  being  attached  by  a 
screw  to  the  end  of  the  metallic  stem,  may  be  replaced  by  others 
of  different  diameters.     These   progressively   increasing   diameters 
are  sliown  by  the  circles. 

Abdominal  Clay  Electrode. 

Auiaud  Itouth  devised  a  flat  tray,  into  the  upper  part  of  which  a  plate- 
electrode  is  fixed.  The  clay  is  placed  in  this  tray,  and  if  it  be  kept  in  a 
shallow  basin  of  salt  water  the  electrode  is  always  ready  for  use,  and  the 
mess  caused  by  the  clay  is  avoided. 

Inglis  Parsons  uses  copper  and  lead  plates  with  an  insulator  which  surrounds 
the  edges  ;  about  six  layers  of  linen,  damped  with  water,  are  placed  between 
the  plates  and  the  skin.  The  patient  can  hold  the  electrode  in  position 
herself. 

There  are  also  required  a  Gaiffe's  galvanometer,  a  water  rheostat,  the 
former  to  measure  the  strength  of  the  current,  and  the  latter  to  equalize  and 
regulate  it. 


Fig.  G3o, — Eigid  Platinum  Sou>-d. 

Apostoli  claimed  for  galvano-chemical  cauterization  that  it  gave  relief  in 
the  following  conditions  : — 

Fibroid  of  the  uterus — polypi.  Oophoralgia. 

Hypertrophj'  of  the  uterus.  I        Ovaritis  and  periovaritis. 

Sub-involution.  Salpingitis. 

Acute  and  chronic  metritis — endo-  '        Ovarian  and  tubular  cysts  at  an 


metritis. 

Ulceration  of  the  neck  of  the  uterus. 

Peri-uterine  inflammation  (parame- 
tritis, perimetritis,  phlegmon). 


early  stage. 
Atresia. 
Hsematocele. 
Malignant  disease  (Byrne). 

Apostoli  specially  insisted  on  these  precautions  :  most  careful  preliminary 
testing  of  the  battery ;  avoidance  of  shock  or  jerk  by  a  progressive  increase 
of  the  dose,  close  attention  to  the  regulating  rheostat  and  galvanometer, 
careful  adjustment  of  the  intra-uterine  insulated  sound,  according  to  the  size 
of  the  uterus,  proper  application  of  the  abdominal  electrode  to  a  healthy  skin, 
avoidance  of  all  force  with  the  sound,  and  thorough  protection  of  the  vagina. 
He  divides  the  operation  itself  into  three  stages.  The  first  embraces  the 
passage  of  the  sound,  the  close  attention  to  the  galvanometer,  and  the  counte- 
nance of  the  patient,  the  avoidance  of  the  infliction  of  pain. 

We  should  commence  slowly,  very  slowly,  to  turn  on  the  cells,   especially 


1006  DISEASES   OF   WOMEN. 

if  it  be  the  first  operation  undertaken,  or  if  we  should  not  be  acquainted  with 
the  patient;  at  first  we  go  to  20  or  30  milliamperes.  Then  proceed  to  50: 
by  this  time  we  gain  the  confidence  of  the  patient,  who  will  soon  find  out 
that  the  electricity  does  not  cause  much  pain.  Then  reach  70,  80,  or  100 
milliamperes,  and  it  is  better  at  this  first  sitting  not  to  go  beyond  this  figure. 
It  is  biportant  >rEVEK  to  :NrAKE  the  patient  sufeek  too  jircH,  and 

XEVEIl   TO    INFLICT   MOKE   PAIN  THAN  IS  BEARABLE.      ThIS   IS  THE   TRUE  CEI- 

terion  which  should  fix  the  LIMIT  OF  THE  DOSE.  It  Will,  of  coursc,  vary 
with  each  patient  and  each  disease,  but  the  success  of  the  operation  depends 
on  adhering  to  this  rule.  That  is  why  we  should  apply  the  current  at  the 
beginning  slowly  and  progi-essively  in  fractional  doses,  and  then  be  guided 
by  the  replies  of  the  patient  in  order  to  gauge  what  she  is  capable  of 
supporting. 

The  second  stage  lasts  for  about  five  minutes,  but  may  extend  to  eight  or 
ten,  never  so  long  in  nervous  and  hysterical  women.  The  steadiness  of  the 
needle  shows  the  continuous  character  of  the  circulating  current.  The  third 
stage  consists  of  the  gradual  stoppage  of  the  current,  and  the  slow  withdrawal 
of  the  sound. 

The  after  treatment  is  most  important.  All  movement  should  be  prohibited. 
The  patient  should  lie  down  at  full  length  during  a  time  varying  from  one 
to  several  hours.  The  nature  of  the  uterine  colic  that  often  supervenes 
should  be  explained  to  her.  A  sanguineous  or  sero-purulent  discharge  may 
follow.     This  is  treated  by  A^aginal  antiseptic  douching. 

Galvano-puacture. — This  involves  all  the  same  precautions  as  are  taken  in 
the  galvano-caustic  application.  In  the  case  of  vaginal  fluctuating  tumours, 
complete  asepsis  of  the  vagina  must  be  first  secured.  Rest  in  bed  is  essential 
after  each  puncture.  The  trocar  should  be  the  smallest  possible,  and  should 
not  pierce  further  than  from  one  half  to  one  centimetre.  The  rectum  and 
bladder  must  be  carefully  avoided,  any  arterial  pulsation  being  looked  for  by 
the  finger,  and  the  insulated  trocar  guided  to  the  point  of  puncture  by  it.  No 
speculum  is  used.  Without  anajsthesia  from  20  to  50  milliamperes  is 
sufficient  as  a  dose.  When  we  go  above  this,  from  100  to  250  milliamperes, 
an  anaesthetic  is  essential.  Elevation  of  temperature  contra-indicates  any 
electrical  treatment. 

In  the  case  of  galvano-puneture  for  fibroid  tumours,  the  following  precau- 
tions have  to  be  taken  : — 

1.  Absolute  and  regular  antiseptic  irrigation  of  the  vagina,  before  and  after 
each  operation. 

2.  Use  as  the  puncturing  instrument  a  small  steel  trocar  or  needle,  and  let 
the  punctures  be  shallow,  not  deeper  than  two  or  three  centimeti'es. 

3.  Make  the  punctures  in  the  most  prominent  part  of  the  fibroid  whenever 
possible  in  the  posterior  cul-de-sac. 

4.  Make  the  punctures  without  a  speculum.  Slide  the  trocar  through  the 
celluloid  sheath  which  protects  the  vagina,  after  having  examined  and  chosen 
by  touch  the  point  where  the  puncture  is  to  be  made. 

5.  Ascertain  the  seat  of  any  pulsation,  so  as  to  avoid  wounding  an  im-. 
portant  vessel. 

6.  In  case  of  any  unusual  hBemorrhage,  immediately  dilate  the  vagina  witli 


GYNMOOLOairM.    r.LI'U  'TRO-  TllEnM'KUTK'H.  1007 

ail  expanding  spcculiiiu,  iuui  if  necessary   [)ut  a  pressure   lorceps  on    tiic 
lileeiling-point. 

The  positive  pole  is  the  express  remedy  for  the  hscmorrhagic  cases,  the 
negative  for  the  non-haimorrhagic,  Apostoli  reconnnends  the  positive  pole 
in  endometritis,  ulcei'ation,  menibranons  dysmenorrhoca,  and  hajraorrhage  ; 
the  negative  i)ole  in  non-luvimorrhagic  cases  of  fibroid  tumour,  in  the  chronic 
stages  of  subacute  perimetritis  after  the  positive  pole  has  l)een  used,  in  the 
non-lucmorrliagic  forms  of  chronic  metritis  and  endometritis,  in  galvano- 
pnnctnres,  and  in  pyo-salpinx,  combined  with  strict  antiseptic  precautions ; 
also  for  galvano-puncture  of  fibroid  tumours,  and  in  draining  Hactuating 
vaginal  tumours. 

Apostoli  emphasizes  the  point  that  the  actions  here  referred 
to  are  not  electrolitic,  and.  Buckmaster*  and  Hayes  f  point  out 
that  thei'e  is  a  chemical  change  at  the  poles  influencing  the 
various  tissues  of  the  tumour.  Hayes  contends  that  oxygen  and 
acids  are  liberated  about  the  positive  pole,  double  the  amount  of 
destruction  of  tissue  occurring  at  the  negative  one.  He  considers 
that  there  ai-e  three  factors  present — ^one  physical,  due  to  the 
liberation  of  gases ;  the  second  chemical,  due  to  the  separation  of 
the  salts  of  the  body  into  the  acids  at  one  pole  and  the  alkalies  at 
the  other  ;  and  thirdly,  a  physiological  effect,  the  exact  nature  of 
which  is  not  understood. 

*  Brooklyn  Med.  Jour.,  Nov.,  1888.  t  Brit.  Gtjn.  Jour.,  liSS'J. 


CHAPTER    LI, 
MASSAGE. 

ly  view  of  the  importance  of  treatment  by  massage  in  various 
affections  incidental  to  women,  I  devote  a  few  observations  to  it  as 
a  fitting  conclusion  to  this  work.  As  the  name  implies,  massage  by 
itself  simply  means  (//acrcroj)  handling  or  manipulating.  We  have 
in  massage,  as  in  many  other  arts,  an  exemplification  of  the  old 
adage,  that  '  there  is  nothing  new  under  the  sun.'  for  the  ancient 
Greeks  and  Romans  availed  themselves  of  this  plan  of  treatment, 
and,  indeed,  long  before  them  the  Chinese  had  skilled  rubbers. 

It  is  my  object,  in  these  few  observations,  to  give  my  personal 
experience  of  the  use  of  massage  in  the  various  affections  for  which 
I  have  employed  it,  and  to  emphasize  some  matters  of  importance  to 
the  practitioner  who  wishes  to  have  an  intelligent  appreciation  of 
this  plan  of  treatment. 

Some  Varieties  of  Massage. 

By  effleurage  is  meant  a  iieculiar  stroking  movement  made  with  the  palm 
of  the  hand,  centripetal] y,  in  the  course  of  the  veins  and  lymphatics,  and  in 
the  direction  of  the  muscular  fibres. 

B}^  petrissage  is  meant  the  deeper  kneading  of  the  muscles  by  a  movement 
of  combined  rolling  and  pressing,  the  muscle  being  seized  and  squeezed,  the 
movement  being  made  in  a  centripetal  dhection. 

By  friction  we  understand  a  combined  movement  of  the  finger-ends  of 
Ijoth  hands,  one  being  carried  across  the  axis  of  tlie  limb  by  re}ieated  strokes, 
and  the  other  in  the  axis  of  the  limb. 

By  tapotement  we  imply  the  percussion  of  the  muscle  or  limb  with  the 
finger-tips,  or  percussor.  or  with  the  back  of  the  half-closed  hand.  Most 
masseuses  rub  with  oU,  vaseline,  or  lanolin.  This  is  advisable  in  some  cases, 
though  for  my  own  part  I  prefer  '  dry '  massage,  and  I  find  patients  like  it 
better,  as  a  rule.  With  it,  as  MuiTell  points  out,  you  have  more  muscular 
contraction,  and  the  electrical  currents  are  more  readily  developed  in  the 
tissues. 

By  vibration.  This  is  done  either  through  electric  power  or  by  the  hand 
of  the  masseur  or  masseuse. 

I  gTOup  these  various  methods  of  action  under  the  general  term  massage, 


JlAS.^AdE.  J  111  If) 

and  include  with  these  manipulations  certain  liexions  and  extensions  or 
movements  that  are  of  necessity  often  combined  with  them  in  practising 
massage.  Yet  the  physiological  fact  must  be  remembered  that  the  nature  of 
the  stimulus,  i.e.  its  character  and  mode  of  api)lication,  applied  to  a  muscle, 
influences  not  alone  the  kinetic  energy  of  the  muscle,  but  also  the  force  and 
distribution  of  the  reflex  impulses;  we  do  not  get  the  same  results  wiih 
stroking  as  we  do  with  either  vibration  movements  or  tapotement.  With  deep 
kneading  we  have  a  different  result  from  that  obtained  by  both  of  the  former 
acts. 

I  may  brietly  summarize  the  more  important  physiological  effects  of 
massage  on  muscle,  nerve,  vascular  distribution,  and  lymphatic  supply. 

Muscles. 

The  chemical  and  physical  changes  consequent  upon  stimulation  of  muscles 
and  muscle  action,  which  modern  physiological  research  has  established  : 

(a)  Generation  and  discharge  of  carbonic  acid. 

(b)  Absorption  of  oxygen. 

(c)  Creation  of  lactic  acid  and  otiier  chemical  changes  in  the  muscle. 

(d)  Probable  slight  increase  in  muscle  temperature. 

(e)  Slight  alteration  in  bulk  of  the  muscle,  attended  by  changes  in  tlie 
blood-supply,  both  in  quantity  and  character. 

(_/')  Generation  of  reflex  impulses.  With  regard  to  this  effect,  it  has  to  be 
remembered,  as  Foster  remarks,  that  '  a  muscle,  even  putting  aside  the  visible 
terminations  of  the  nerve,  is  fundamentally  a  muscle  and  a  nerve  besides.' 

(g)  Readier  response  to  electrical  stimuH  after  massage,  and  probable  elec- 
trical changes  ;  during  massage,  excitation  in  the  muscle-nerves  excited. 

(/()   An  influence  on  unstriated  muscular  peristalsis. 

Nerves. 

Chemico-physical  molecular  changes  in  the  nerve-tissue  starting  both 
sensory  and  motor  impulses ;  these  centripetal  impulses  affect  the  central 
ganglia,  and  influence  both  automatic  and  reflex  actions.  The  phenomenon 
of  inhibition  is  manifested.  Analgesia  is  produced  by  prolonged  and  con- 
tinued pressure. 

The  Vascular  Mechanism. 

The  main  effects  are  to  be  seen  in  the  peripheral  arterial  resistance.  The 
peripheral  resistance  is  generally  lessened  (at  times  may  be  temporarilj- 
increased)  by  massage.  This  is  principally  due  to  the  following  effects ; 
Altered  nutrition  of  parts ;  change  in  the  peripheral  vaso-motor  control ; 
reflex  stimulation  of  the  vaso-motor  centres ;  altered  blood-pressure  due  to 
the  presence  of  carbonic  acid  and  loss  of  oxygen  (according  to  Sommerbrot,* 
intra-bronchial  pressure  taking  an  important  part  in  this  action  on  the  heart). 

*  Sommerbrot:  ' Ueber  eine  bisher  nicht  gekanntc  wiehtige  Einrichtung  des 

meusobliclien  Organisruus.'     Tubingen,  ISSl. 

3    T 


1010  DrSEASES   OF    WOMEN. 

These  effects  are  manifested  in  the  blood-pressure  and  arterial  tension,  primary 
diminution,  secondary  increase. 

The  heart's  action  may  be  influenced  by  (a)  the  local  reflex  effects  on  the 
skin  and  muscle,  or  through  the  abdominal  nerves,  during  abdominal  massage, 
from  splanchnic  inhibitory  action ;  (b)  by  the  alteration  in  the  arterial  pressure, 
either  local  or  general,  brought  about  by  the  massage.  Such  vascular  changes 
are  necessarily  attended  by  a  local  determination  of  blood,  by  alteration  in 
the  velocity  of  the  blood  cm-rent,  in  tlie  metabolic  tissue  changes,  in  the 
nutrition  of  the  parts  manipulated,  in  the  comparative  rapidity  of  the  removal 
of  excrementitious  material.  More  especially  important  are  such  physiological 
effects  if  manifested  in  the  case  of  the  portal  and  renal  circulations. 


Lymphatics. 

In  deep  massage  of  the  extremities,  or  kneading,  the  centripetal  flow  of 
lymph  in  the  tendon  and  fascia  lymph  vascular  spaces  is  expedited.  This 
will  be  the  case  also  in  the  tendinous  and  fascial  structures  composing  a  great 
part  of  the  abdominal  wall ;  the  processes  of  absorption  and  resorption  are 
promoted;  lymphatic  glandular  activitj^  is  excited.  The  same  occurs  in  the 
more  superficial  lymph  vessels  from  stroking  the  skin  and  vibration  move- 
ments. Daring  deep  abdominal  massage  a  powerful  influence  must  be 
exerted  on  the  lymphatic  vascular  mechanism  and  on  the  nature  of  the  fluid 
in  the  lacteal  vessels.  This  will  result  directly  from  the  continued  or  inter- 
mittent mechanical  pressure  exerted  through  the  abdominal  wall,  indepen- 
dently of  the  altered  relations  between  the  superficial  and  deep  lymph  currents 
and  the  bloodvessels.  It  must  also  follow  from  the  effects  of  massage  on 
the  portal  circulation.  I  allude  to  the  more  rapid  reception  by  the  portal 
blood  of  the  products  of  digestion  which  find  their  way  into  it.  This  tem- 
porary increased  diversion  of  food  elements  necessarily  influences  the  chyle 
and  the  tension  of  the  lacteal  vessels.  Also,  in  general  massage,  followed  by 
abdominal,  through  the  continued  suction  effects  of  increased  respiratory 
movements  and  general  (primarj')  diminished  venous  pressure,  the  lymphatic 
flow  is  temporarily  encouraged,  while  through  the  nei'vous  influence  on  the 
abdominal  vascular  system  generally,  lymphatic  absorption  is  promoted. 

These  physiological  facts,  necessarily  modified  by  the  local  anatomical 
relationships,  can  be  well  applied  to  the  pelvic  structures  in  which  gynae- 
cologists are  more  especially  interested. ' 

We  may  correlate  such  physiological  effects  of  massage  with 
the  more  manifest  clinical  phenomena  and  effects  noticed  in  its 
practice. 

(1)  Sliglit  immediate  changes  in  hody  teinperature.  These  are  not  constant, 
and  vary,  Avith  rare  exceptions,  to  the  extent  of  a  degree  more  or  less  ;  of  this 
I  have  satisfied  myself  several  times.  There  is  occasionally  a  fall ;  this  is  not 
so  common  as  a  slight  rise. 

(2)  Decided  increase,  as  a  ride,  in  muscle  nutrition  and  ])ower  of  endurance  ; 
increase,  of  muscle  lueir/h  t. 


.]fASSA<;E.  loll 

(3)  Restoration  of  reflex  excitability  in  weakened  muscles,  and  the  improv(d 
association  of  reflex  and  automatic  action. 

(4)  Reduction  of  cutaneous  and  muscular  hyper xsthesia,  and  relief  of  j>ain 
arising  from  refledid  irritations  in  distant  reyions. 

(o)  Increased  effects  of  galvanism  after  massage,  necessitating  reduction  in 
the  strength  of  the  current,  and  increased  care  in  its  employment, 

(6)  ImproL-ed  peristaltic  action,  as  shown  in  the  case  of  the  nonstriated 
abdominal  muscles  of  the  intestines  and  the  cesopliageal  muscles. 

(7)  Imprroved  nutritive  nerve  changes,  as  v:e  find  in  the  case  of  muscle. 
These  are  shown  in  restored  nerve  function,  in  healthier  brain  action,  in  the 
production  of  sleep,  in  alleviation  of  perverted  and  distorted  mental  symptoms. 

\>i)  Improvement  in  the  tone  and  character  of  the  pulse  under  maksage. 
This  good  influence  on  a  sluggish  circulation  is  exhibited  in  the  eflfect  on  cold 
extremities  ;  the  same  result  is  seen  in  cases  of  rhythmic  irregularitv  of  iieart 
due  to  torpid  hepatic  circulation,  flatus,  and  abdominal  obesity. 

The  occasional  attack  of  syncope,  which  I  have  seen  in  a  few  instances,  is 
the  effect  of  either  a  reflex  inhibitory  stoppage  of  the  heart's  beat,  or  faintness 
arisuig  from  rapidly  lowered  arterial  pressure.  In  some  patients  vascular 
and  nervous  excitement  are  so  pronounced  when  head  massage  is  tried  that 
it  has  to  be  abandoned.  This  is  shown  in  suffusion  of  the  face  and  ej'es,  sense 
of  weight  in  the  head,  mental  excitement,  hysterical  crying ;  these  symptoms 
are  followed  by  con-esponding  mental  depression. 

9)  Absorption  of  fat  and  loss  of  weight  due  to  removal  of  excrementitious 
material  and  useless  fat,  with  improved  digestive  powers.  In  these  women 
menstruation  is  frequently  irregular,  or  they  suffer  from  amenoiThoea,  They 
are  also  often  sterUe.  For  such  patients  the  therapeutic  use  of  massage  must 
be  combined  with  the  enforcement  of  dietetic  rules  and  avoidance  of  fat- 
forming  food. 

[By  an  examination  of  the  urine  passed  before  and  after  the  massage,  we 
can  see  for  ourselves  the  effects  on  the  secretion.] 

(10)  Reabsorption  of  lymph  effusions  and  various  exudations  ;  reduction  of 
glandidar  hyperplasias. 

AVhile  thus  enumerating  the  physiological  and  clinical  effects  of  massao-e, 
as  experienced  under  favourable  conditions  of  temperament  and  physique. 
and  aided  frequently  by  other  therapeutical  means — such  as  galvanism  or 
faradism,  baths,  medicinal  agents,  special  dietary — it  must  be  stated  that  the 
process  is  frequently  attended  by  various  exaggerated  or  unexpected  results, 
in  some  or  all  of  the  directions  enumerated,  which  completely  contra-indicate 
its  employment.  It  is  not  a  course  to  be  i/rescribed  or  recommendfd  in  a 
careless  or  cursory  manner. 

While  massage  is  a  form  of  exercise  in  some  of  its  methods,  exercise  is  not 
massage.  Manual  massage  differs  widely  from  exercise,  gymnastic  or  other, 
in  (a)  the  nature  of  the  excitation  ;  (b)  the  power  of  its  limitation  to  defined 
areas ;  (c)  the  direct  action  on  the  bloodvessels,  lymphatics,  and  nerves  ;  (d) 
the  comparatively  slight  evolution  of  body  heat ;  [e)  tlie  passive  attitude  of 
the  subject;  (/)  the  absence  of  the  more  complex  actions  of  a  reflex  and 
automatic  nature,  with  the  associated  cerebral  inhil)itory  supervision,  which 
are  the  necessary  attendants  on  exercise.     The  more  complicated,  or  the  more 


1012  DISEASES   OF    WOMEN. 

finely  adjusted,  such  exercises,  the  more  widely  do  they  depart  in  their  nature 
from  the  manipulation  of  massage.  We  might  as  well  compare  the  effects  of 
the  necessary  manipulations,  and  the  physical  labour  or  fatigue  of  the  ma'^  -euse 
with  those  on  the  person  rubbed. 

Uses  in  G-ynsecology. 

(1)  In  atonic  conditions  generally,  both  of  muscles  and  nerves,  as, 
for  instance,  relaxed  abdominal  walls  ;  intestinal  flatulent  disten- 
sion ;  chronic  tympanitic  states ;  chronic  constipation ;  those  forms 
of  general  debility  and  lassitude  complicating  menorrhagia,  subin- 
volution, and  other  chronic  uterine  affections. 

(2)  In  reflex  neuroses  arising  from  or  complicating  morbid  states 
of  the  generative  organs  in  women ;  so-called  cases  of  irritable 
spine  ;  reflex  headache  ;  cases  of  '  uterine  lameness  ; '  neuro-mimesis 
of  joints ;  torticollis. 

(3)  In  amenorrhoea  and  dysmenorrhoea,  especially  those  cases 
associated  with  anaemia  and.  chlorsemia. 

(4)  In  neuralgias  of  tJie  pelvic  nerves — oophoria ;  in  neurasthenic 
coccygodynia. 

(5)  In  morbid  obesity. 

(6)  In  neurosis  due  to  masturbation. 

(7)  In  hysterical,  neurasthenic,  or  hypochondriacal  patients  who  have 
no  organic  disease. 

(8)  In  glandular  hyperplasia. 

(9)  In  mammary  infiltrations,  in  chronic  mammary  hardening,  in 
threatened  milk  coagulation,  in  mammary  neuralgia. 

(10)  In  chronic  constipation  and  costiveness.  Massage  is  particularly 
useful  in  cases  of  fsecal  accumulation.  I  believe  the  proper  treat- 
ment for  the  more  obstinate  of  such  cases  to  be  dilatation  of  the 
sphincters  and  emptying  of  the  rectum,  followed  by  galvanism  and 
deep  massage  of  the  abdomen. 

Massage  for  Constipation. — When  massage  is  practised  for  constipation,  the 
woman  should  get  into  the  knee-elbow  position :  the  masseuse  kneels  behind 
and  massages  the  colon  in  its  course  from  the  csecum  to  the  sigmoid.  This 
is  done  by  petrissage  and  vibratory  movements.  The  entire  abdomen  is  next 
manipulated.  Lastly,  the  sponge  of  the  constant-current  battery  is  carried 
over  the  entire  course  of  the  colon. 

Combined  Internal  and  External  Massage. 

Only  those  affections  are  here-  referred  to  in  which  I  have  had  ample  per- 
sonal proofs  of  the  benefit  of  massage.      Combined  internal  and  external 


l/.l.vN.w./.;.  Kii:; 

massage  I  do  not  iiic-ludo.  It  is  needless  tu  insist  on  the  cure  which  is 
necessary  in  carrying  out  such  a  plan  of  treatment.  How  far  abuse  of  it  has 
been  practised  we  need  not  discuss.  How  far  possible  advantages  may  be 
overbalanced  by  the  certain  evils  it  is  not  difficult  to  surmise.  There  have 
been  onlj'  too  numerous  examples  of  this  abuse  of  massage  brought  to  light 
from  time  to  time. 

Personally,  I  have  no  experience  of  its  value  in  metritis,  ovarian  tumour, 
perimetritis,  cystitis  and  uterine  tumours,  and,  not  having  tried  its  efficacy,  1 
do  not  express  any  opinion  on  the  results  of  this  treatment  in  the  hands  ol 
those  who  have. 

^lassage  and  pelvic  gymnastics  have  been  practised  by  Brandt  of  Stock- 
holm, Schauta,  and  others,  especially  in  descent  and  prolapse  of  the  uterus. 
Schultze's  manipulative  treatment  of  retroversion  has  been  referred  to.* 
It  consists,  briefly,  of  (1)  elevation  of  the  uterus  by  a  plan  of  combined 
internal  and  external  manipulation,  followed  by  (2)  massage  of  the 
uterus  and  its  ligaments,  principally  by  external  movements  in  the  direc- 
tion of  the  internal  os  from  the  fundus,  the  uterus  being  supported 
against  the  abdominal  wall  by  the  assistant's  flnger  in  the  vagina.  These 
uterine  movements,  etc.,  are  followed  by  (3)  pelvic  gymnastics,  the  patient's 
thighs,  as  she  lies  in  the  lithotomy  position,  being  forcibly  abducted,  while 
she  resists,  at  the  same  time  that  she  raises  the  sacrum  from  the  couch,  and 
supports  herself  on  the  elbows  and  feet.  Lastly  (4)  tapotement  of  the  lumbar 
and  sacral  vertebrae  is  practised  with  the  clenched  fist.  Alfred  Smith  devised 
a  uterine  elevator  which  the  patient  can  herself  use  to  raise  the  uterus,  and 
thus  avoid  the  necessity  for  an  assistant's  fingers  in  the  vagina.f 

Dangers  of  Massage. — It  would  seena  supertluou.s  to  speak  of  the 
dangers  attending  the  use  of  massage  in  pelvic  inflammations,  and 
the  risks  of  an  uacertainty  of  diagnosis  both  as  to  the  situation  and 
character  of  effusions,  but  that  in  works  on  massage  its  employment 
is  advised  bj  various  authorities  in  these  conditions.  The  respon- 
sibility of  administering  it  in  acute  pelvic  cellular  or  peritoneal 
inflammations  should  rest  with  no  one  save  a  qualified  medical 
manipulator.  Even  in  cases  of  chronic  lymph  or  serous  exudations 
in  the  pelvis,  no  nurse  should  be  entrusted  with  the  administration 
of  internal  massage,  and  no  one  should  advise  it  save  a  physician 
"well  versed  in  the  diagnosis  of  such  diseases. 

I  have  been  consulted  by  patients  who  were  'rubbed'  for  fibroid  tumour 
and  ovarian  cyst.  The  kinetic  energ}^  here  might  have  been  more  safely 
expended  on  the  lady's  boots.  Not  long  since  a  patient  with  contracted 
vulvar  orifice,  tubercular  degeneration  of  the  vaginal  wall,  and  severe  uterine 
haemorrhage,  consulted  me.  The  hairaorrhage  was  stopped.  I  nest  learned 
that  she  was  being  '  rubbed.'     A  lady  friend  recommended  it,  and  a  doctor, 

*  See  chapters  on  Displacements. 

t  Smith.  '  Transactions  of  the  Academy  of  Medicine  in  Ireland,  1889.' 


1014  DISEASES   OF   WOMEN. 


without  seeing  her,  had  sent  the  masseuse.  She  was  being  '  cured.'  The  next 
thing  I  heard  of  her  was  that  she  was  dangerously  ill.  Death  followed 
shortly  afterwards.     This  is  an  example  of  the  vulgar  abuse  of  massage. 

Conclusions. 

All  medical  men  who  resort  to  massage  would  do  well  to  take 
these  precautions — ■ 

1.  To  select,  after   careful  personal    inquiry  and  questioning,  their    own 

masseuse,  who  must  be  an  intelligent,  cheerful  woman,  with  excep- 
tional tact  and  decision  of  character.  She  requires  strength  of  body 
as  well  as  of  will,  while  with  these  there  must  be  combined  gentleness 
and  patience.  She  must  be  a  woman  calculated  to  inspire  hope  and 
confidence,  and,  above  all,  reticent  in  speaking  of  other  patients  or 
their  ailments. 

2.  To  see  that  she  has  some  elementary  knowledge  of  anatomy  and  physi- 

ology, and  the  position  of  the  muscles  and  bones. 

3.  To  regulate  the  kind  and  the  times  of  massage ;  the  intervals  of  rest, 

exercise,  and  the  dietary. 

4.  If  pursuing  the  Weir-Mitchell  plan  of  rest,  feeding,  and  seclusion,  per- 

sonally to  watch  its  effects  on  the  patient,  and  not  to  adopt  this  method 
of  treatment  without  careful  supervision. 

It  is  well  to  endeavour  to  have  a  modified  system  of  massage  (so 
far  as  is  possible)  persevered  in  for  some  time  after  the  patient  is 
removed  home. 

5.  To  begin  in  most  cases  with  general  massage  of  the  extremities,  trunk, 

and  back-muscles,  gradually  practising  abdominal  massage.  This  rule, 
of  course,  does  not  apply  to  those  cases  in  which  abdominal  massage 
is  especially  indicated. 

6.  Not  to  use  massage  immediately  before  or  after  meals,  although  some 

light  nourishment  may  be  taken  previous  to  the  rubbing.  The  patient 
should  generally  rest  for  an  hour,  and,  if  she  sleep,  should  not  be 
disturbed.  When  she  wakes  she  may  be  given  a  seaweed  or  pine 
bath,  and  be  well  rubbed  down.  Then  she  should  have  her  drive  or 
light  exercise.  The  best  time  for  massage  is  in  the  morning.  I  prefer 
the  hour  of  eleven  a.m.  The  diu'ation  of  the  seance  will  depend  on 
the  nature  of  the  case.  Two  short  seances  in  the  day  are  sometimes 
better  than  one  prolonged  massage.  The  practitioner  will  find  that 
much  of  the  success  of  his  treatment  will  depend  on  the  type  of 
woman  he  selects  for  his  cases. 

Vibration  Treatment  of  Fibromata  and  Adnexal  Affections. 

Jayle  and  De  la  Croix  cle  Lavalette  *  first  treated  uterine  and 
adnexal  affections   by  mechanical  vibrations   (Sismotherajpic  mecha- 
nique).     Sismotherapic  treatment  has  the  advantage  of  being  very 
*  Revue  de  Gyn^cologie,  Pozzi..  July-August,  1899. 


.)fASSA(lK. 


mi. 


simple — ^any   one   c;iu    practise    it ;    and    there  is   no  necessity   for 
vaginal  manipulations. 

They  claim  for  it  that  it  is  a  palliative  thciapeutic  method  which 
can  be  employed  in  all  cases  in  which  no  suppurative  conditions  of 
the  adnexa  are  present,  or  other  suppurative  states  of  the  pelvis. 
Cases  are  reported  in  which  tibromas  have  been  successfully  treated 
so  far  as  the  reduction  of  the  size  of  the  tumour  and  the  arrest  of 
haemorrhage  are  concerned.  Relief  of  congestion  of  the  pehic 
basin,  and  improvement  of  the  intestinal  circulation,  are  brouj^ht 
about. 


Fig.  Goi. — ArrLicATiuN  in  the  EiiCLiNiNO  Position-  .\nd  with  a  Fingeb 

MAKING   PrESSUKE   IN   THE   VaGINA. 

The  indications  for  the  treatment  are  fibromas  with  haemorrhage, 
inter-menstrual  fluxes,  erratic  pelvic  pains,  general  nerve  states, 
chronic  salpingo-oophoritis  of  a  non-suppurative  character,  general 
debility,  when  attendant  upon  some  disorder  of  the  female  genital 
organs,  and  gastric  intestinal  atony. 

Appliances. — There  are  various  vibrators.  A  largeone  for  intercliaiigeable 
excitations;  a  small  hand  machine  in  which  there  is  a  dynamo  mounted 
on  a  socket  and  fixed  to  a  handle.     Dilferent  exciters  may  be  attached 


lOKi 


DISEASES   OF    WOMSm 


Fig.  635. — Electrical  Motor  and  Cable  with  Stem. 


Fig.  636. — Electrical  Hand  VinRATOR. 


.^ASSAdF. 


101- 


to  this  liaiid  apparatus.  It  is  recharged  with  an  urdinary  commuuicalur. 
The  third  is  the  machine  shown  in  the  text.  It  is  composed  of  a  small 
electrical  motor  which  acts  directly  with  an  alternative  current  of  110  volts, 
giving  a  force  of  15  kilogrammetres  with  a  rapidity  of  1800  to  2000  revolu- 
tions to  the  minuto.  This  stands  on  a  small  table  alongside  the  bed,  and  on 
this  is  placed  a  short-circuit  apparatus,  an  interrupter  and  rheostat  enabling 
the  operator  to  regulate  the  rapidity  of  tlie  motor.  The  table  is  so  connected 
with  the  current  from  the  main  by  a  flexible  cable  as  to  enable  it  to  be 
attached  to  the  socket  of  any  incandescent  lamp.  The  rotatory  movement 
is  transmitted  to  a  concuteur,  which  is  directly  attached  to  the  cylinder  of  the 
motor.  The  vibratory  motion  is  thus  transmitted  through  the  small  pads 
attached  to  the  plaque,  which  is  fixed  to  a  stem  that  is  connected  with  the 
Hoxible  cable  by  a  form  of  bayonet  catch,  and  thus  the  plaque  has  conveyed 
to  it  the  necessary  vibratory  movement.  The  i)laque  is  now  applied  to  the 
part  it  is  desired  to  massage,  and  the  movement  is  communicated  to  it.  The 
sitting  laets  from  ten  to  twenty  minutes.     The  morning  hour  after  the  break- 


Few  Goxcutkuks. 


fast  meal  is  the  preferable  time,  and  the  patient's  bowel  and  bladder  should 
be  emptied  before  the  massage  is  commenced.  After  each  sitting  the  patient 
should  rest  for  a  quarter  of  an  hour  on  the  back  or  in  the  prone  position. 
There  need  be  no  interruption  of  the  patient's  occupation,  though  it  is  not 
well  that  she  should  overdo  exe.-cise  while  the  treatment  is  being  carried  out. 
During  the  application  the  woman  should  lie  on  her  back,  and  the  vibratory 
plate  is  simply  applied  to  the  abdominal  wall  on  a  level,  say,  with  the  fibroma, 
if  it  should  be  used  for  a  tumour;  or  one  or  two  fingers  of  the  left  hand  are 
introduced  into  the  vagina,  and  counter-j  ressure  is  made  from  within  in  the 
direction  of  the  part  to  which  the  application  is  being  made.  No  pressure, 
however,  should  be  such  as  to  prevent  the  vibrations  from  traversing  the 
abdominal  wall  or  the  pelvic  organs.  The  treatment  may  have  to  be  con- 
tinued from  some  six  weeks  to  three  months.  More  patience  is  demanded 
for  the  completion  of  the  cure  than  we  are  likely  to  secure  from  the  majority 
of  patients. 


CHAPTER   LII. 

SOME  EUROPEAN  SPAS  INDICATED  IN  PELVIC 
AND  OTHER  ASSOCIATED  AFFECTIONS  OF 
WOMEN. 

We  are  often  consulted  as  to  the  spa  the  waters  of  which  are  specially  indi- 
cated for  the  particular  case  under  consideration.  The  following  tables  are 
inserted  for  ready  reference,  and  from  them  a  selection  may  be  made.  The 
list  does  not  by  any  means  include  the  names  of  all  the  Continental  spas. 
Those,  however,  are  selected  which  are  universally  regarded  as  the  most 
efficient  for  the  particular  diseases  embraced  in  each  table.  The  nature  of 
tlie  water  of  each  spa  is  roughly  indicated.  Of  our  British  spas,  that  of 
Woodhall  for  inflammatory  pelvic  conditions,  tumours,  and  old  exudations  ; 
those  of  Han'ogate,  Strathpeffer,  Llandrmdod  Wells  in  anaemic  states; 
of  Bath,  Harrogate,  Lisdoonvarna,  Llandrindod  Wells,  Strathpeffer,  Buxton, 
in  gouty  conditions,  obesity,  and  defective  biliary  metabolism  generally ;  of 
Bath,  Buxton,  Harrogate,  and  Leamington,  in  affections  of  the  urinary  organs ; 
AVoodhall  Spa  in  tubercular  states  and  glandular  enlargements,  are  respec- 
tively the  most  powerful.  Where  a  pelvic  affection  is  complicated  by  a 
rheumatic  state,  Droitv/ich  baths  and  Woodhall  are  the  two  for  selection. 

{The  nature  of  the  vjater  is  roughly  given,  and  the  situation.') 
Pelvic  Affections  of  Wojien. 


XAME.                                    CHAEACTER    OF    WATER. 

SITUATION. 

*Aachen     (Aix  -  la 

Chapelle) 

Syphilitic  conditions  ... 

Rhenish  Prussia. 

Adelheidsquelle    . . 

i.  Salts,  with  iodine  and  bromide 

Bavaria. 

Bareges      

Sulphurous      ...         

Hautes-Pyre'nees. 

Bourboule,  La 

Highly  arsenical        

Puy-de-D6me. 

*Brides-les-Bains  .. 

i  Alkaline           

Savoy. 

*Carl8bad 

j         ^j                   

Bohemia. 

Carlsbrunn 

Ferruginous  (effervescing)   ... 

Silesia. 

Eaux-Chaudes 

Sulphurets  with  chlorides     ... 

Basses-Pyrenees. 

Ems            

Alkaline 

Duchy  of  Nassau. 

Les  Escaldas 

Sulphurous,  etc.          

Pyre'ne'es-Orientales.    i 

*rranzensbad 

Ferruginous;  alkaline 

Bohemia. 

*  Those  spas  marked  with  an  asterisk  are  ones  which  the  author  can  moat 
strongly  recommend  in  affections  of  the  pelvic  organs  of  women. 


//  riJj: 02' A  TIIIC    TREA  TMEyi—SI'AS. 


Kllii 


SPAS  (continued). 
Pki.vic  Affections  of  Womkn  {fontinu&T). 


CHARACTER   OF   WATEK. 


♦Wilbad-GastciQ 
*Kis8iDgen 
♦Krcuznach  t 

*M!irienbad 
Ncnndorf   . . . 

*Plombieres 

*Royat 
Salins-Moutiers 

*Sa)somaggiorc 

Uriage 
*Woodhall   ... 


Electrical         

Saline  (chlorides)       

Saliue;  strongly  iodized;  mud 
batlis...         

Ferruginous  and  alkaline     ... 

Sulphates  and  saline... 

Various;  ferruginous 

Arsenical  and  iron 

Various ;  ferruginous,  chlo- 
rides, and  iodides 

Bromine,  iodine,  and  ferrugi- 
nous   

Saline;  sulphurous 

Bromine  and  iodine 


Duchy  of  Salzburg. 
Bavaria. 

Rhenish  Piutsia. 
Austro-Hunsiiiy. 
North-west  G  orraauy. 
Vosges. 
Puy-de-Dome, France. 

Savoy. 

Prov.  Emilia,  Italy. 
Isl-re,  France. 
Lincolnshire. 


AxiEMic  State?. 


Bagnures  de  Bigorre 

Carlsbrunn 

Chatel-Gyon 

*Fplixstowe 

Flitwick    

*Franzensbad 

Harrogate 

Lenco        

*Marienbad 

Pyrmont     ... 

Eippoldsau 
*Royat         

*Sal8omaggiore 
*Schwalbach 

*S 


pa 

*Stahlbrunnen 
Homburg 
Strathpeffer 
Tunbridge  Wells 
Vala 


of 


Ferruginous  and  arsenical    ... 

Ferruginous     

Chlorurets  of  sodium  and  mag- 
nesium, and  ferruginous    ... 

Ferruginous     ... 
Alkaline;  ferruginous 
Sulphurous  and  ferruginous... 
Ferruginous  and  arsenical    . . . 
Ferruginous  and  saline 
Ferruginous 
Saline;  chalybeate     ... 
Arsenical  and  iron 

Ferruginous 


Ferruginous  and  sulphurous 
Ferruginous    


Haute.s-Pyre'ne'es. 

Silesia. 

Puv-de-DOme. 

Suffolk. 

Bedfordshire. 

Bohemia. 

Yorkshire. 

Trentino,  Austria. 

Austro-Hungary. 

"Waldeck. 

Black  Forest. 

Puv-de-D6me.  France 

(1,480  feet). 
Prov.  EmUia,  Italy. 
Nassau. 
Belgium. 

Central  Germany. 

Perthshire. 

Kent. 

Ardeche,  France. 


t  Woodhall  Spa  water  is  in  every  respect  equal  to  Kreuznach,  and  is  a  more 
powerful  bromated  spa.  Also,  the  climate  is  not  so  enervating  as  that  of  the 
German  resort. 


1020 


DISEASES   OF    WOMEN. 


SPAS  {continued). 
Glandular  Okgans  (Tuberculous  Affections). 


NAME. 

CHARACTEK   OF   WATER. 

SITUATION. 

Ashby-de  -la-Zouch 

Eaux-Bonnes 

Eaux-Chaudes 

*Ischl           

*KreuzDach 

Leamington 

Leuk          

Lichtenthal 

*Marienbad 

*Eeichenhall 
*Salsomaggiore 
*Sankt  Moritz 

*Tarasp        

*Woodhall  Spa 

Saline 

Alkaline  sulphates     

Sulphurets;  chlorides 

Sulphurous      

Bromine  and  iodine  ... 
Chlorides 

Sulphates,  etc.            

Ferruginous     ... 

Alkaline           

Saline   ... 

Ferrugimus     

Alkaline           

Bromine  and  iodine   ... 

Leicestershire.              , 
Basses-Pyrene'es. 

Austria. 

Rhenish  Prussia, 
Warwickshire. 
Switzerland. 
Baden. 

Austro-Hungary. 
Upper  Bavaria. 
Prov.  Emilia,  Italy. 
Switzerland. 

Lincolnshire. 

Defective  Biliary  Metabolism  and  Gout. 


*Aix-les-Bains 
*Aix-la-Chapelle    . 
*Baden-Baden 

Baden 

*Bath 
Bilin 

*Bourboule,  La 
*Brides-les-Bains  . 
*Buxton 
*Carlsbad     ... 

Cheltenham 
*Contrexe'ville 

Ems 

*  Harrogate  ... 
*Homburg  ... 
*Kis8ingen  ... 

Leamington 
*Lisdoonvarna 
*Llandrindod  Wellg 

*Marienbad 

*Nauheim  ... 
*P]ombieres 

Pougues 
*Strathpefifer 
*Vals 

*  Vichy         


Sulphurous      

Alkaline  and  sulphates 
Alkaline ;  chloride  of  sodium 

Alkaline 

Alkaline  and  sulphates 
Alkaline  (carbonates) 

Arsenical,  etc.  

Alkaline  

Various  spas    ... 
Alkaline;  soda  salts  ... 
Various  spas    ... 
Alkaline  

Sulphur;  iron;  saline 
Alkaline,  with  iron  and  sulphur 

Saline  (chlori  des)       

Alkaline 
Sulphur,  etc.    ... 

Saline  (with  iron) 
Saline  (chloride  of  sodium)  ... 
Various ;  ferruginous 
Alkaline  and  ferruginous 
Sulphur  and  sulphates,  etc. ... 
Alkaline   and   alkaline   earth 

(bicarbonates) ;  various  spas 
Alkaline  and  alkaline   earth 

(bicarbonates) ;  various  spas 


Savoy. 

Ehenish  Prussia. 

Duchy  of  Baden,  Ger- 
many. 

Austria  —  outside 
Vienna. 

Somersetshire. 

Bohemia. 

Puy-de-D6me,France. 

Savoy. 

Derb3^shire. 

Bohemia. 

Gloucestershire. 

Vosges. 

Germany. 

Yorkshire. 

Central  Germany. 

Bavaria. 

Warwickshire. 

Co.  Clare,  Ireland. 

Brecknocksh.,  Wales. 

Bohemia. 

Hessen-Nassau. 


Nievre,  France. 
Ross-shire. 

Ardeche,  France. 

Central  France. 


HVI>Px  0 PA  THIC    TJi  I'JA  TMENTSPA  S. 


lu-jl 


SPAS  {continued). 
Defective  Biliary  Metabolism  and  Gout  {continued). 


1 

1                      NAME. 

CHAKACTER    OF    WATER. 

SITUATION. 

♦Vittel         

♦Wiesbaden 
*Wilbad       

Various  salts  (sulphates  and  bi- 
carbonates  of  lime  and  mag- 
nesia; iron,  and  manganese) 

Saline  (chlorides) 

Electrical  baths          

Vosges. 
Nassau. 
Black  Forest. 

1 

Affections  of  the  Urinary  Organs. 


Baden-Baden 

Chloride  of  sodium  (arsenic  and 

lithium) 

,  Duchy  of  Baden. 

*Buxton       

Various ;    carbonate   of  lime  ; 

iron 

Derbyshire. 

Carlottenbrunnon . . . 

Chalybeate      

Silesia  (whey  cure). 

*Carlsbad     

Alkaline;  soda  salts 

Bohemia. 

*Contrexe'ville 

Alkaline           

Vosges,  France. 

*Ems            

...         ...         ••• 

Nassau. 

*Harrogate  ... 

Various  sulphur  spas;  also  iron 

and  saline     ... 

Yorkshire. 

;  *Homburg 

Alkaline,  with  iron  and  sulphur 

Central  Germany. 

*Kis8ingen  ... 

Saline  (clilorides) 

Bavaria. 

Mannheim 

Saline 

Central  Germany. 

Marienbad 

Alkaline  and  ferruginous 

Bohemia. 

Montecatini 

i?  aline,  various 

Lucca,  Italy. 

Neueuahr  

Alkaline           

Klieuish  Prussia. 

*Vals            

Alkaline  and  alkaline  earth  (bi- 

1 

carbonates)  ;  various  spas . . . 

Ardeche,  France. 

1*  Vichy         

Alkaline  and  alkaline  earth  (bi- 

carbonates)  ;  various  spas  ... 

Allier,  France. 

*  Vittel 

Alkaline;  V'larious  salts  (Grande 

Source)          

Vosges,  France. 

Wilduugen 

Alkaline           

Waldeck. 

Affections  op  the  Nervous  System. 


Ems             

Alkaline;  muriatic 

Duchy  of  Nassau. 

*\Vilbad-Gastein    ... 

Electrical         

Duchy  of  Salzburg. 

Levico 

Ferruginous;  arsenical 

Trentino,  Austria. 

Marienbad 

Ferruginous;  alkaline 

Austro-Hungary. 

*Nauheim    ... 

Saline  and  ferruginous 

Hessen-Nassau. 

Plombieres 

Various;  gas  baths 

Vosges. 

*Rippoldsau 

Saline  effervescent;  chalvbeate 

Black  Forest. 

Kagatz 

France. 

'    Salins         

Various             

Savoy. 

St.  Sauveur 

France. 

Teplitz-Schonau  ... 

Alkaline  and  saline 

Austria. 

1 

INDEX 


For  Instruuients  and  Appliances,  see  end  of  Index. 
For  Names  referred  to  in  text,  see  List  of  Authorities , 


Abdomen  : 

examination  of,  83-86 

measurements  of,  61,  84 

palpation  of,  84 

paunched,  754 

percussion  of,  85 

sterilization  of,  128 

toilet  of,  134 
Abdominal  wound, 

dressing  of,  538 

examination  of,  544,  545 

re-opening  of,  545-548 
Abscess  : 

of  vulvo-vagiual  glands,  3,  826 

pelvic,  159 

rectal,  972 

sub-urethi-al,  886,  887 
Absence  of  genitalia,  42,  176,  807,  852 
Adenoma : 

of  cervical  glands,  550 

of  ovarv,  737-739 

of  uterus,  321,  415-420 
Adhesions,  422-424,  480,  494,  502,  505, 
513,  661 

diagnosis  of,  7,  61,  762 
Adnexa : 

conservative  operations  on,  683- 
687 

position  of,  480 
Adrenalin,  819 
Alcoholism,  729 
Amenorrhoea,  171-184 

causation  of,  172 

confounded  with  pregnancv,  172- 
174 

diagnosis,  172 

treatment,  181-184 
Amputation  : 

of  cervix,  302-304,  320 

of  uterus,  321 
Anfemia  and  chlorosis,  174 

pre^^ous  history  in,  175 

treatment  of,  177 


Anaesthesia,  local,  79 
Auffisthetics  : 

choice  of,  75-80 

in  examinations,  91 

rules  for  administration  of,  78 
Analgesia,  spinal,  79 
Angioma  of  liver,  953 
Angiotripsy,  509,  510 
Animal  extracts,  583 
Anteflexion  of  uterus,  193,  238-244 

operations  for,  242,  243 
Anteversion,  233-238 
Antiseptics,  125 
Aperients,  195-197,  985 
Appendicitis,  42,  364,  956 
Appendix  : 

anatomy  of,  41 

concretions  of,  43 
Appliances.     See  end  of  Index 

for  examination  of  case,  51,  52, 
56-82 

for  examination  in  private  house, 
116 

sterilization  of,  116 
Arteries,  ligation  of,  456,  457 
Artificial  serum,  536 
Ascent  of  uterus,  811,  312 
Asepsis  and  antisepsis,  107-141 

differentiation  of,  109-111 

importance  of,  107-109 

in  operating  theatre.  111 

in  private  house,  114 
Aspiration,  144 

Atmocausis  and  zestocausis,  336-342 
Atresia  : 

of  uterus,  851,  854 

of  vagina,  851,  855 

of  vulva,  798 
Attendant  in  study,  60 

Bactkriology,  137-140 
Bathing,  180 
Balloon,  vesical,  908 


1024 


INDEX. 


Bladder : 

affections  of,  894-919 

calculus  in,  913 

cancer  in,  910,  914 

changes  in,  906,  910 

cystitis,  904,  905 

cystoscop;^  of,  895 

dilatation  of,  901 

drainage  of,  908 

examination  of,  894 

exstrophy  of,  902 

hypersemia  of  trigone,  903 

irritability  of,  903,  904 

malformations  of,  902 

papilloma  of,  918 

prolapse  of,  309 

sarcoma  of,  916 

stone  in,  911,  912 
\^    surgical  treatment  of,  897,   907, 
•        911-913,  917,  918 

tuberculosis  of,  910,  911 

tumours  and  growths  of,  914-919 
Bowel : 

management  of,  537,  540,  583 

perforation  of,  365 

protection  of,  481,  543 
Broad  ligaments  : 

anatomy  of,  18,  19 

cysts  of,  669,  742 

division  of,  482 

fibromata  of,  474 

tightening  of,  265 

Vineberg's  operation  on,  277 
Bronze-aluminium  wire,  121 

Calculi,  893,  911.  934,  935,  961-963 
Cancer  : 

age  in,  563 

choice  of  operation  in,  589 

complications  of,  569 

constipation  in,  583 

correlation  of  pelvic  lymphatics 
in,  552,  553 

diagnosis  of,  671-673 

differentiation  of,  565,  578 

discharge  of,  569 

electro-thermic    hsemostases    in, 
499,  501 

forestage  of,  551 

hsemorrhage  in,  581 

implantation  of,  553 

in  pregnancy,  565,  600 

influence    of    Ijonphatic     distri- 
bution on,  585 

inoperable,  583,  584 

invasion  of,  555 

microscopical     examination     of, 
560,  561 

of  cervix,  553,  567,  587 

of  Fallouian  tubes,  679 

of  kidney,  45,  950 

of  ovaries,  742 


Cancer  (continued) : 

of  portio  vaginalis,  567 

of  rectum,  981 

of  uterus,  550-604 

of  vagina,  864-866 

of  vulva,  808,  820 

pathogeny  of,  551,  552 

physical  signs  of,  570,  571,  672 

predisposing  causes  of,  562 

prognosis,  579 

renal  complications  in,  569 

sedatives  in,  581 

symptoms  of,  567,  577 

treatment  of : 

palliative  and  general,  580- 

584 
surgical,  584,  587-604 

varieties  of : 

adenoma  malignum,  550 
carcinoma,  553,  563-566 
chorion  epithelioma,  605-619 
medullary,  558-560 
scirrhus,  557 

vascular  supply  of,  558 
Catheters,  use  of,  136,  924 
Cauterization,  347,  924-929 
Cautery,  galvanic,  144 
Cervical  glands,  adenoma  of,  550 
Cervix : 

amputation  of,  302-304,  320,  587- 
589 

cancer  of,  553,  567,  587 

cysts  of,  357,  358 

degeneration  of,  356-358 

depletion  of,  143 

dilatation  of,  393,  394 

division  of,  144,  145,  242,  243 

elongation  of,  286 

erosion  of,  352-358 

examination  of,  391 

hypertrophy  of,  367 

incision  of,  242-244 

laceration  of,  386-391 

scarification  of,  356 

stenosis  of,  22,  242,  243 

tuberculosis  of,  631 
Childbed,  examination  in,  391 
Children : 

cystomata  in,  733 

disease  of  Fallopian  tubes  in,  731 

gonorrhoea  in,  734,  735 

ovarian  disease  in,  92,  731 

pelvic  organs  of,  92 

rectal  exploration  in,  92 

sarcoma  in,  868 

vulvo-vaginitis  in,  824-826 
Chorion-epithelioma,  866 
Chloride  of  zinc  treatment,  347,  588 
Climacteric,  44,  53 
Clinical  thermometer,  value  of,  75    , 
Glitoridectomy,  224 
Clitoris,  3,  4,  807 


INDEX, 


1026 


Clitoris  (continued) : 

Dilatation  (continued) : 

anatomy  of,  3 

importance  of,  393,  894 

carcinoma  of,  SOS 

in  myoma,  429 

fibroma  of,  809 

of  sphincter  ani,  197 

Closure  of  abdominal  wound,  134 

of  urethra,  S91,  892 

Coccygodynia,  987-989 

Discharges,  56,  95-98,  569 

Coeliotomy,  •iGG-'lGS 

Displacements,  uterine,  233-825 

in  tuberculosis  of  genitalia,  645 

Distension,  tjanpanitic,  537 

Colpectomy,  307 

Douglas'  pouch,  13 

Colpocystotomy,  918 

Drainage,  135,  370,  371 

Colpoperiueorrhaphy,  300-304 

Dressings,  sterilization  of,  116-123 

Colporrhapby,  308 

Dysmenorrha3a,  171,  186-204 

Colpotomy,  787-790 

causes  of,  189-194 

Conservative  operations,  683-G87 

classification  of,  171 

value  of,  780-782 

electrolysis  in,  204 

Constipation,  195-197,  583,  985 

galvanism  in,  199 

Curettage,  155-161,  262,  330,  336 

in  poljTDUS  uteri,  201,  393,  394 

dangers  of,  24,  159,  161 

operative  interference  in,  145, 194, 

value  of,  155 

210 

Cutaneous  affections  of  vulva,  809 

pain  of,  186,  202 

Cycling,  dangers  of,  179 

pigmentation  in,  189 

Cystitis,  904-907 

symptoms  of,  190 

bacteria  in,  905 

treatment  of,  195-204 

causation  of,  904 

use  of  pessaries  in,  236-238,  244, 

gonorrhoeal,  909 

255-258 

post  operative,  909 

varieties  of: 

treatment,  906-908 

congestive,  189 

tubercular,  910 

membranous,  203 

m-ine  in,  910 

neuralgic,  201 

Cystocele,  complicating  prolapse,  279 

obstruction,  189-194 

Cystoscopv,  895 

ovarian,  189 

Cystotomy,  907,  911,  913 

spasmodic,  190-192 

Cysts : 

Dyspareunia,  567,  816,  839,  992,  997 

blood,  727,  829 

broad  ligament,  669,  742 

EcHiNOCOCCUS  of  genitalia,  861,  951. 

congenital,  886 

See  Hydatid  cysts 

dermoid,  739,  742 

Eclampsia,  98 

Gartnerian,  744 

Ectopic  gestation.    See  Extra-uterine 

hydatid,  860,  950,  951 

pregnancy 

of  Fallopian  tubes,  659 

Eczema  of  vulva,  810,  811 

of  kidney,  949,  950 

of  urethral  orifices,  920-922 

of  labia,  3 

Electro-therapeutics,  999-1007 

of  m-ethra,  886 

appliances  for,  1003-1005 

of  vagina,  860 

dangers  of,  1000 

papillomatous,  745-747 

galvano-caustic  method,  1004 

paroophronic,  742 

galvano-puncture,  1006 

retro-rectal,  742 

indications  for,  1001 

ruptm-e  of,  384 

limit  of  dose,  1006 

precautions  after  operations,  1006 

Deciduoma  Malignum.    See  Chorion- 

Electrothermic  htemostases,  496-504 

epithelioma 

advantages  of,  496,  504 

Dental  pulp,  congestion  of,  189 

Elephautiases,  830-832 

Dermoids,  662,  739,  742 

Endometrectomy,  342 

Descent  of  uterus.     Sec  Prolapse 

Endometritis,  328,  336,  342-347 

Diagnosis : 

chronic,  331 

errors  in,  435-440 

fungous,  575 

the  microscope  in,  88 

hfemorrhagic,  334 

the  ophthalmoscope  in,  98 

hj-perplastic,  336 

Dilatation : 

treatment  of,  336-347 

bv  tent,  80,  81,  429 

tubercular,  682 

dangers  of,  80,  159,  160 

Endometrium,    micro-organisms     in. 

forcible,  81,  82,  913,  984 

139 

3  u 


1026 


INDEX. 


Endo-salpingitis,  656,  682 
Endothelioma  of  ovary,  776 

of  rectum,  986 
Enemas,  986 
Episiorrhaphy,  304 
Erosion  of  cervix,  352-358 
Esthiomenic  menstrual  ulcer,  53 
Examination  of  a  case,  51-106 

abdominal,  83 

appliances  necessary  for,  51,  52, 
56-82 

conjoined,  87 

in  childbed,  391 

position  for,  57-61 

rectal,  87 

vaginal,  86 
Exploratory  incision,  105 
Exstrophy  of  bladder,  902 
Extirpation  of  vagina,  603 
Extra-uterine  pregnancy,  688-717 

abdominal,  692 

complications  in,  715 

conditions  mistaken  for,  708,  709 

description  of,  688 

diagnosis  of,  707 

etiology  of,  689 
Eye-strain  in  women,  103 

F^CAL  tumours,  971 
Fallopian  tubes : 

adhesions  of,  25,  661,  686 

affections  of,  648-687  i 

artificial  ostium,  684 

carcinoma  of,  679,  680 

catheterization  of,  25 

closure  of,  653 

cysts  of,  659 

dermoid  of,  662 

disease  of,  in  children,  731 

hsemato-salpinx,  662,  666,  667,674 

haemorrhage  in,  675 

papilloma  of,  686 

patency  of,  25 

pathological  changes  in,  676 

pyo-salpinx,  662,  667-670, 676, 678 

rupture  of,  700-703 

salpingitis,  26,  651-662 

salpingocele,  682 

specific  affections  of,  659 

sterilization  of,  686 

structure  of  walls  of,  649,  650 

tuberculosis  of,  636-642,  646-648 

twisted,  675 
Fat  thrill,  85 
Fibro-cystic  tumours,  411-414,  754 

differentiation  of,  432 

etiology  of,  411 
Fibromyoma.     See  Myomas 
Fistula,  868-882 

anal,  877 

causation,  870 

foecal,  549 


Fistulse  {continued) : 

operations  for,  872-882 

rectal,  972,  973 

recto-vaginal,  877 

symptoms  of,  871 

treatment  of,  875 

vaginal,  809,  869-882 

varieties  of,  869 

vesico-utero-vaginal,  878 

ureteral,  935-937 
Fixation  of  uterus,  270 
Folliculitis,  824-826 
Forcipressure,  533 
Foreign  body  in  ovary,  718 

Galvanism,  199 
Gangrene  of  vulva,  827 
Genitalia : 

absence  of,  42,  176,  807,  852 

and  insanity,  221-232 

tuberculosis  of,  620-647 
Gonococci  in  tubal  walls,  658 
Gut  and  silk,  sterilization  of,  118-121 

HiEMATOCELE,  378-385 

puncture  of,  149,  150,  370 
Heematoma,  pudental,  830 
Heemato-salpinx,  641,  666,  667,  674 
Haemorrhage : 

in  cancer,  568 
internal,  763,  857 
pelvic,  379-385 
prolonged,  473 
secondary,  526,  546 
symptoms  of,  546 
treatment  of,   160,  443,  446,  484, 
493,  503,  526,  546,  581,  979 
Htemorrhoids,  974-979 
in  pregnancy,  971 
Hsemostasis,  electrothermic,  496-504 
Health  resorts  and  spas,  178, 1018-1021 
in    affections     of     the     nervous 

system,  1021 
in  affections  of  the  urinary  organs, 

1021 
in  ansemic  states,  1019 
in  defective  biliary  metabolism, 

1020,  1021 
in  gout,  1020 

in  x^elvic  affections,  1018,  1019 
in  strumous  affections,  1020 
Hegar's  sign  in  pregnancy,  174 
Hepatoptosis,  44 
Hermaphrodism,  799-807 
classification  of,  799 
diagnosis  of,  803 
psychical  effects  of,  806 
secondaji'y  characteristics  of,  802 
Hernia: 

into  labium,  3,  833 

of  ovary,  717,  833 

-  post-operative,  166 


INDEX. 


1027 


Horpos  of  ^1^1va,  811,  812 

iGNI-PONaTDBB,  683 

Hot-air  troatmont,  37G 

Ileus,  542,  543 

Hot  baths,  clangors  of,  101,  817 

Incision  of  cervix  uteri,  242-244 

Pfydatid  cysts,  G75,  950,  951 

Incontinence  of  urine,  17 

Hydrastis,  433 

Indications     for     salpingo-oiiphorcc- 

Hydroceles  of  roiiud  ligament,  4, 

833 

tomy,  782 

Hydronephrosis,  952 

Inflammation : 

Hydrorrhoaa,    intermittent    ovarian. 

of  urinary  tract,  423 

652 

of  uterine  tissues,  326-351 

Hydrosalpinx,  G67-G70 

pelvic,  359-377 

Hymen  : 

Injections,  intra-uterine,  152,  153 

ablation  of,  841 

Insanity  and  the    female    genitalia. 

abnormalities  of,  11 

220-232 

anatomy  of,  9 

differentiation  of,  222 

bearing  on  chastity,  11,  12 

examination  in,  225,  230 

folding,  11,  12 

masturbation  in,  223 

imperforate,  12 

operation  in,  221-232 

malformations  of,  858 

pubescent,  224 

Hyperi-cmia,  326-328, 432, 433,  720, 903 

use  of  ovarine  in,  232 

Hypnotics.     See  Sedatives 

Internal  os,  division  of,  145 

Hysterectomy.    See  also  Panhyst 

erec- 

Intra-uterine  crayons  and  bougies,  153 

tomy 

injections,  152 

abdominal,  500 

medication,  150 

accidents  in,  493 

stems,  244 

adhesions  in,  422-424, 480, 500, 543 

suppositories,  154 

after-treatment  of,  525,  526 

Inversion  of  uterus,  313-325 

appliances  required  for,  475 

Iodoform  poisoning,  717 

artificial  sermn  in,  536 

Iron  in  amenorrhoea,  181 

Baer's  method,  510 

Irrigation,  594 

by  angiotripsy,  496,  509-515, 

527 

by  ligature,  510,  512,  515-523 

Kidney  : 

combined  method,  526 

adenoma  of,  95 

complications  in,  493,  494, 

505- 

affections  of,  945-963 

509,  511,  514,  539-543 

calculus  of,  961-963 

Doyen's  methods,  527,  530,  595 

carcinoma  of,  45,  950 

drainage  in,  488 

causes  of  enlargement,  948-950 

duties  of  assistants  in,  593,  594 

complicating  uterine  disease,  45 

electro-hsemostases  in,  496-504 

cysts  of,  949-951 

fistulse  in,  549 

examination  of,  941 

for  cancer,  501,  690-601 

fibroma  of,  949 

for  prolapse,  308,  311 

hydro-nephrosis  of,  949,  952 

for  uterine  myoma,  471-533 

landmarks  of,  946 

haemorrhage  in,  493 

movable   or   displaced,   45,   955- 

Howard     Kelly's    method, 

447, 

960 

505-509 

puncture  of,  961 

indications  for,  451 

pyo-nephrosis  of,  949 

Landau's  method,  533 

relation  to  gynfecology,  945 

morphia  after,  537 

renal  enlargements  of,  945,  946 

obesity  in,  476 

sarcoma  of,  950 

pan.     See  Pan-hysterectomy 

surgical  treatment  of,  961 

post-operative     treatment, 

525, 

tuberculosis  of,  944-949 

526,  535-549 

tumours  of,  955 

sacral  method,  603 

Kobelt,  bulb  of,  3, 

shock  during,  493,  534-536 

Kraurosis  vulvae,  814 

supra-vaginal,  447,  505-514 

vaginal,  449,  498,  515-533, 

590, 

Labium  : 

595 

anatomy  of,  3 

with  colporrhaphy,  308 

cancer  of,  820 

Zweifel's  method,  509 

cysts  of,  829 

Hysteria,  186 

hernia  into,  3,  833 

treatment  of,  200 

inflammation  of,  826 

vaginal  examinations  in,  20C 

Lactation,  prolonged,  753 

1028 


INDEX. 


Laparotomy,  effects  in  tuberculosis, 
645 

Leucorrhoea;  181-185 

Ligaments : 

cysts  of  the  broad,  669,  742 
fibromata  of  the  broad,  474 
shortening  the  sacro-uterine,  265, 

305-307 
tightening  the  broad,  265 

Ligation  of  arteries,  456,  457 

Ligatures.    See  Sutures  and  ligatures 

Lithotrity,  912,  913 

Mania,  climacteric,  53 
Massage,  1008-1017 
abdominal,  1012 
combined  internal  and  external, 

1012,  1013 
dangers  of,  1013,  1014 

gynaecological,  258-261 

physiological  effects  of,  1009-1012 

rules  for  application  of,  1014 

iises  in  gynfficology,  258,  1012 

varieties  of,  1008,  1009 

vascular  mechanism  of,  1009 

vibratory,  1014-1017- 
Medication,  intra-uteriue,  150 
Menopause,  affections  of,  53,  54 
Menorrhagia  and  metrorrhagia,  204- 
210,  393,  394 

treatment,  205-210 
Menstrual  congestion  of  dental  pulp, 
189 

ulcer,  53 
Menstruation,  29-38 

accidental  influences  on,  175 

disorders  of,  171-210 

importance  of,  55,  56 

mental  disturbance  in,  223,  225 

physiology  of,  38 

pigmentation  in,  188 

pseudo-,  38 

retained  menses,  857 

vicarious,  52 

views  on,  34-38 
Metritis,  328-331 

Micro-organisms,  137-140,  361,  905 
Minor  gynaecological  operations,  142- 

161 
Mole,  tubal,  678 
Morcellation,  469-472 
Morphia : 

abuse  of,  198,  199 

employment  of,  581 

suppression  of,  199 
Morphiomania,  198 
Myomas,  uterine,  399-549 

adeno-,  415-420 

adhesions  of,  422-424 

calcification  of,  410 

complications  of, 

adnesal,  422,  423 


Myomas,  uterine  {continued) : 
complications  of, 

by  pregnancy,  435,  440-442 

degenerative,  406 

extra-uterine,  406,  407 

psychical,  407 
dangers  of,  420-424 
degenerations  of,  406,  411-414 
development  of,  401-403 
diagnosis  of,  425,  427 
differentiation  of,  427-429 
etiology  of,  399 
fibro-,  411 
giant,  412 
growth  of,  403,  404 
haemorrhage  in,  433 
lameness  caused  by,  62,  404 
risk  of  operations  for,  449-455 
submucous,  472 
symptoms  of,  430 
treatment  of, 

palliative,  432-434 

surgical,  445-549 
varieties  of,  405,  406 
Myomectomy,  465,  468,  473 

Nbphrorehaphy,  960 

Nerve-strain,  219 

Nerve  trunks,  spread  of  infection  by 

554 
Neurosis,  uterine,  211-219 
Nitric  acid,  application  of,  142 
Nose,  the,  as  a  genital  centre,  189 

Obesity,  476 
Obstruction,  540,  543 
Occupation,  influence  of,  54 
Ocular  disturbances,  98-105 
Oophorectomy,  467,  458 
Operating-room,  111-114 
Operations : 

asepsis  in,  107-141 
complications  in,  480,  493 
duties  of  assistants  in,  593,  594 
mortality  and  risks  of,  266, 449-455 
plastic,  243 
post-operative  treatment  of,  525, 

526,  535-549 
preparation  of  patient  for,  128-130 
preparation  of  surgeon  and  nurses 

for,  123-128,  130-133 
risks  of,  449-455 
unfavourable  cases  for,  797 
varieties  of : 

Alexander's,  267 
ablation  of  hymen,  841 
amputation  of  cervix,302-304, 

587 
aspiration,  858 
bisection  of  uterus,  463 
clitoridectomy,  224 
coeliotomy,  466-468 


INDEX. 


1029 


Operations  (contimied) : 
varieties  of : 

colotomy,  983 
colpcctomy,  307 
colpo-periueorrhaphy,      298, 

300-304 
colporrhaphy,  308 
colpo-cystotomy,  787-790 
conservative,  883-887 
curettage,  155-lGl,  262,  330, 

336 
cystotomy,  907,  908,  911,  913 
decortication,  449,  474 
division  of  cervix  uteri,  144, 

145,  242,  243 
endometrectomy,  342 
episiorrliapliy,  304 
excision  of  vagina,  307 
extirpation  of  vagina,  603 
for    atresia    of    vagina    and 

uterus,  858-860 
for  cancer  of  rectum,  982-984 
for  cancer  of  uterus,  584,  587- 

604 
for  cancer  of  vagina,  865 
for  coccygodpiia,  989 
for   complete  tear  of   recto- 
vaginal septum,  296-299 
for   displacements,    241-244, 

263-277 
for     fistulte,     549,    872-882, 

936,  973 
for  formation  of  new  urethra, 

888 
for  hsemorrhoids,  975-979 
for    incontinence    of    urine, 

913,  914 
for     inversion     of      uterus, 

321-325 
for     laceration     of     cervix, 

389-391 
for   laceration  of   perineum, 

290 
for  myoma,  445-549 
for  opening  uterine  canal,  858 
for  ovarian  cystoma,  779-797 
for  pelvic  inflammation,  367- 

372 
for  poh^pus  uteri,  396 
for   prolapse,    288-290,    300, 

308-311 
for  pruritus,  820 
for  rectal  stricture,  980 
for  rectocele,  300-302 
for  relaxed  vaginal  outlet,  295 
for  restraining  haemorrhage, 

446 
for  retained  menses,  858 
for    shortening    utero-sacral 

ligaments,  305-307 
for  stricture  of  rectum,  980 
for  transplantation,  38,  828 


Operations  (continued) : 

varieties  of : 

for  vaginismus,  841,  842 
for  vegetations  of  vulva,  828 
hysterectomy.     See  separate 

heading 
incision  of  vagina,  397 
in  insanity,  225 
minor  gynecological,  142-161 
myomectomy,  465,  468,  473 
nephrorrhaphy,  960,  961 
nephro-u.rcterectomy,  944 
oophorectomy,  779-790 
ovariotomy,  790-797 
pan-hystorectomy.    See  sepa- 
rate heading 
paracentesis  abdominis,  147 
perineorrhaiDhy,  290-295 
puncture  of  kidney,  961 
puncture  of  vagina,  370 
salpingo-ofiphorectomv,  457- 

465,  687,  779-790 
salpingorrhaphy,  685 
salpingostomy,  685 
salpingostraphy,  685 
suspension  of  uterus,  271 
traction   throvigh  ligaments, 

277 
vaginal  fixation,  272-277 
vaginal    punction,    148-150, 

370 
ventro-fixation,  270 
uretero-cystotomy,  942-944 
uretero-ureterostomy,     940- 
942 

verification  of  sponges,  etc.,  after, 
791 
Ophthalmoscope  in  diagnosis,  98-103 
Osteomalacia,  718 
Os  uteri,  anatomy  of,  21,  22 

stenosis  of,  22 
Ovarian  cystoma,  736-764 

adhesions  of,  761,  762 

complicating  i^regnancv,  748,  749 

contents  of,  737,  739-74'l,  743,  745 

development  of,  736 

diagnosis  of,  751 

examination  for,  752 

haemorrhage  into,  763 

history  of,  752-754 

inflammation  of,  762 

ruptui'e  of,  384 

sjonptoms  of,  384 

treatment  of,  763,  790-797 

varieties  of : 

adenomatous,  737 
dermoids,  739-741 
Gartneriau,  744 
oophoronic,  737 
papillomatous,  745-747 
paroophoronic,  742,  743 
parovarian,  744 


1030 


INDEX, 


Ovarian  (continued) : 

varieties  of : 

racemose,  745 
suppurating,  757,  758,  762 
Ovarian  gestation,  691 
Ovarian  solid  tumours,  765-778 

carcinoma,  773-775 

characteristics  of,  776 

classification  of,  776 

endothelioma,  777,  778 

fibromata,  767-770 

gyroma,  777,  778 

Krugenberg's,  775 

myoma,  771 
Ovaries : 

abnormalities  of,  719 

affections  of,  718-797 

anatomy  of,  27 

apoplexy  of,  727 

carcinoma  of,  742,  773-775 

cirrhosis  of,  723 

classification  of,  721 

conservative  operations  on,  688 

cysts  of,  727,  739.  See  also  Ovarian 
cystoma 

degeneration  of,  724-726 

development  of,  718 

disease  of,  in  children,  731-733 

displacements  of,  719 

endothelioma  of,  776-778 

examination  of,  752-754 

fibroma  of,  765-770 

foreign  body  in,  718 

gyroma  of,  777,  778 

hernia  of,  719 

hypersemia  of,  720 

influence  of  retroversion  on,  247 

"irritable,"  730 

myoma  of,  771 

osteomalacia,  718 

ovaritis,  720-731 

palpation  of,  91 

papilloma  of,  745-747 

sarcoma  of,  772,  773 

sclerosis  of,  723 

secretion  of,  39 

senile  changes  in,  32 

solid  tumours  of,  765-778 

surgical  treatment  of,  779-797 

transplantation  of,  38 

tuberculosis  of,  442,  742 

tumours  of,  765-778 
Ovariotomy,  790-797 

appliances  required  for,  790,  791 

peritoneal  toilet  in,  795 

saline  irrigation  after,  795 

unfavoui-able  cases  for,  797 
Ovaritis,  720-731 

causation,  720,  729 

chronic,  723 

cirrhotic,  723 

cortical,  721 


Ovaritis  (continued) : 

cystic,  729 

diagnosis  of,  730 

etiology  of,  720 

sclerotic,  723 

symptoms  of,  730 
Ovulation,  29-32 

Pain,  35,  187,  190-194,  430,  567,  568, 
581,  753 

relief  of,  434,  537,  731,  985 
Pan-hysterectomy,     See  also  Hyste- 
rectomy 

abdominal,  489,  600-602 

accidents  in,  493 

adhesions  in,  480 

Bumm's,  494,  596-599 

by  electro-hgemostasis,  503 

by  ligature,  475-477 

Doyen's,  311,  489 

drainage  in,  488 

haemorrhage  in,  493 

Martin's,  602 

post-operative     treatment,     525, 
526,  535-549 

Pozzi's,  646 

Pryor's,  523-525 

radical  combined,  596-599 

Eies-Rumpf-Clarke's,  600,  601 

Schuchard's,  600 

shock  during,  493 

vaginal,  321 

Werder's,  599 

Wertheim's,  601 
Paracentesis  abdominis,  147 
Parametritis,  372-377 
Parotitis,  749,  750 
Pelvic  abscess,  159 

fascia,  18-20 

hsemorrhage,  378-385 

inflammation,  359-377 

lymphatics,  552-544 

organs  in  children,  92 

suppurations,  359-364 
Perforation  of  bowel,  365 
Perimetritis   and  parametritis,   359- 
364 

■pathology,  361 

symptoms,  363 
Perineorrhaphy,  290-295 
PeTineum : 

anatomy  of,  13 

immediate  treatment  of,  289 

laceration  of,  13,  289-295 

relaxation  of,  13 
Peritoneal  toilet,  795 
Peritonitis,  420,  540-543 
Pessaries,    remarks    on,    8,   236-238, 
244,  254^258,  284-286 

rules  for  application  of,  236 
Plethora,  175 
Plugging  the  rectum,  979 


INDEX. 


1031 


Polypus  uteri,  357,  358,  392-398,  675 
as  cause   of  dysmenorrhcea  and   [ 
menorrhagia,  393,  394  | 

complicating  prolapse,  281  : 

retrocession  of,  394 
signs  and  symptoms  of,  395  I 

treatment  of,  396 
Position  for  examination,  57-61 
Post-operative  treatment,  534-549         | 
artificial  serum  in,  536  ' 

complications,  540-543 
dressing  of  wound,  538 
feeding  in,  536 
fistulae  in,  549 

hcemorrhage  in,  526,  546,  547 
high  temperature,  541,  549 
management  of  bowel  in,  537 
morphia  in,  537 
reopening  the  abdomen,  544 
shock,  534-536  i 

thirst  and  vomiting,  539 
tympanitic  distension,  537 
Posture,  influence  of,  8 
Pregnancy : 

abdominal,  692 

after  oophorectomy,  780-782 

and  abortion,  54 

and  amenorrhcea,  172-174 

and  pelvic  haemorrhage,  379 

and  tuberciilosis,  635 

and  vaginal  cysts,  863 

cancer  in,  565 

complicating  myoma,  435  111 

complicating     ovarian     tumour, 

746 
comual,  706 

diagnosis  in,  172-174,  185 
examination  of  abdomen  in,  85 
examination  of  uterus  after,  565 
extra-uterine,  688-717 
haemorrhoids  in,  971 
Hegar's  sign  in,  173,  174 
operation  during,  600,  974 
ovarian,  691 
sound  in,  71 
tubal,  693,  703,  704 
Preparation  of  patient,  128-130 

of  surgeon,  assistants,  and  nurses, 
123-128,  130-134 
Procidentia  uteri.     See  Prolapse 
Proctitis,  970 
Proctoscopy,  106,  967-971 
Prolapse : 

complicated  by  cystocele,  280 
bv  elongated  cer\-ix,  286 
by  fibroma,  308 
of  bladder  and  bowel,  309 
of  ovarv,  719,  720 
of  rectum,  984,  985 
of  urethra,  884,  885 
of  uterus,  278,  311 
of  vagina,  286-290,  299-302 


Prolapse  (continued) : 

surgical   treatment   of,   288-290, 
299-302,  307-311 
Pruritus: 

adrenalin  in,  819 

ani,  984 

causation,  813 

operation  for,  820 

treatment,  815-819 

vulvffi,  812-818,  820 
Pseudo-menstruation,  38 
Puncture  of  vagina,  148-150,  370 
Pvelonephrosis,  423 
Pyosalpinx,  370,  667-670, 676, 678, 846 
Pyoureter,  423,  934 

Rectocbile,  283, 300-302 
Recto-Eomanoscopy,  967-970 
Rectum : 

abscess  of,  972 

affections  of,  965-989 

anatomy  of,  40,  41 

attention  to,  in  cancer,  581 

examination  of,  40,  91,  92,  105, 
376,  965-970 

fistula,  972-973 

haemorrhage  in,  979 

haemorrhoids,  40,  974-979 
in  pregnancy,  974 
operations  for,  975-979 

impacted  fseces,  971 

malignant  disease  of,  981-984 

neglect  of,  40,  971,  985 

operations  on,  975-979,  981 

polypus,  935 

proctitis,  970 

prolapse,  984,  985 

pruritus  ani,  984 

rectocele,  283,  300,  301 

stricture,  979,  931 

tumours  of,  971 

ulceration,  979 
Reflexes,  ocular,  98-105 

uterine,  211-219 
Relaxed  vaginal  outlet,  231-234,  295 
Retained  menses,  857 
Retinal  complications,  98-105 
Retroflexion  of  uterus,  253-261 

internal  massage  for,  268 

operations  for,  262-277 
Retroversion,  245-258 
Round  ligaments : 

anatomy  of,  18,  20 

cysts  of  j  834 

hydrocele  of,  3 
i  surgical  treatment  of,  277 

Salete  irrigation,  795 

Saliva  as  a  source  of  infection,  141 

Salpingitis,  651-662 

chronic  atrophic,  657 
classification  of,  652,  661 


1032 


INDEX. 


Salpingitis  [continued) : 

effects  on  menstruation,  640 

etiology  of,  652 

exploratory  incision  for,  651 

gonorrhoeal,  657-659 

nodular,  640,  662 

parenchymatous,  656 

pattiologv  of,  656 

tubercular,  614,  640,  682 
Salpingocele,  682 

Salpingo-oophorectomy,  457-465,  687, 
779-790 

indications  for,  457,  782-787 

pregnancy  after,  780-782 
Salpiugorrhaphy,  685 
Salpingostomy,  685 
Salpingostraphy,  685 
Sarcoma : 

developed  from  myoma,  414 

differentiation,  578 

in  children,  576,  577 

of  ovary,  772,  773 

of  uterus,  575-579 

of  vagina,  866-869 

prognosis,  579 

symptomatology,  577 
Scirrhus,  557 

costive  bowel  in,  583 
Sedatives  and  hypnotics,  197,  581 
Septicemia,  546 
Sexual   function  and  insanity,   220- 

232 
Shock  during  operation,  493,  534-536 
Sound : 

as  a  means  of  diagnosis,  68-73, 
91,  429 

dangers  of,  71,  173 
Spas.     See  Health  resorts 
'  Specula,  varieties  of,  62-69 
Sponges,  preparation  of,  121,  122 

verification   of  number   of,  after 
operation,  791 
Sterility,  990-998 

absence  of  uterus  in,  995 

causation  of,  991-997 

psvchical  influences  on,  996 

treatment  of,  997,  998 
Sterilization.     See  Asepsis  and  Anti- 
sepsis 
Stethoscope  in  examination,  63 
Subinvolution,  349-351 
Sutures  and  ligatures,  162-170 
Syphilis,  347,  819,  821-823 

Tempeeament,  the  Ivmphatic,  215 
the  neurotic,  198-200,  202,  209-2 
19 
Temperature,  high,  541,  548 
Tents,  80,  81,  429 
Thirst  and  vomiting,  539 
Toilet,  peritoneal,  795 
Torsion  of  uterus,  408 


Transplantation  of  ovaries,  38 
Trendelenbtu-g     position,     occasional 

danger  of,  133 
Tubal  abortion,  700-702 

apoplexy,  673 

mole,  698 

pregnancy.       See    Extra-uterine 
pregnancv 

rupture,  700-703 
Tuberculosis  of  genitalia,  620-647 

diagnosis  of,  633 

differentiation  of,  627 

effects  of  laparotomy  upon,  645 

etiology  of,  621 

fibroid  variety,  639 

frequency  of  occurrence,  620,  624 

hereditary  influences,  621 

histology,  635 

in  children,  624 

in  relation  to  menstruation  and 
pregnancy,  635 

of  cervix,  631 

of  Fallopian  tubes,  636-639 

of  fundus  uteri,  631-633 

of  ovary,  642,  643 

of  portio  vaginalis,  630,  631 

of  vagina,  629 

of  vulva,  627-629 

primary,  635,  641-643 

relation  of,  to  menstruation  and 
pregnancy,  635 

sources  of  infection  of,  621-624 

surgical  treatment,  644-646 

symptomatologj',  631 

varieties  of,  635 

Ueetees  : 

affections  of,  920-944 

anatomv  of,  46-49 

calculus  in,  934,  935 

catheterization  of,  924,  925,  927- 
929 

diagnosis  of  obscure  s^nnptoms  in, 
937,  938 

double,  920,  921 

examination  of,  926 

fistulis,  935,  936 
-hydro-ureter,  933 

landmarks  of,  49 

obstruction  of,  932 

palpation  of,  48 

pvo-ureter,  984 

strictm-e  of,  933 

sm-gerv  of,  936-941 

wounds  of,  493,  938-940 
Ureteritis,  922-926 

diagnosis  of,  924 

sjTaptomatology,  923 

tubercular,  932 

varieties  of,  922,  923 
Uretero-cystotomy,  942-944 
Uretero-m'eterostomy,  940-942 


INDEX. 


1033 


Urethra : 

abnormalities  of,  883 

abscess  of,  88G,  887 

affections  of,  883-893 

anatomv  of,  4,  5 

caruncle  of,  889-891 

dilatation  of,  895,  897 

exploration  of,  892 

operations  on,  888 

prolapse  of,  884 

strictui-e  of,  891,  892 
Urethritis,  883,  884 
Urethrocele,  885,  886 
Urine  : 

analyses  of,  842,  843 

examination  of,  73-75 

incontinence  of,  913,  914 

suppression  of,  44 
Uterine  neuroses,  209-219 
Utero-sacral  ligaments,  shortening  of, 

305-307 
Uterus : 

adenomyoma  of,  415-420 

anatoniT  of,  14-17 

anteflexion  of,  193,  238-244 

anteversion  of,  233-238 

ascent  of,  311,  312 

atresia  of,  851,  854 

bisection  of,  463-465 

cancer  of.     See  Cancer  of  Uterus 

changes  in,  17,  18 

curettage  of,  155-161,  262 

descent  of.     See  Prolapse 

displacements  of,  17,  233-325 

fibro-niToma  of.     See  Myomas 

fixation  of,  17,  270-276 

hypertemia  of,  326-328 

iiiflamniation  of,  326-351 

inversion  of,  313-325 

ligaments  of,  18-20 

malformations  of,  852 

mvoma  of,  399-549 

po'lypus  of,  357,  358,  392-398 

prolapse  of,  278-311 

retroflexion  of,  245-258 

sarcoma  of,  575-579 

secretions  of,  23-25 

sub-involution  of,  349-351 

suspension  of,  271,  272 

torsion  of,  408 

traction  on,  277 

tuberculosis  of,  631-635 

vapo-cauterization  of,  336-342 

Vagisa  : 

absence  of,  855,  856 
affections  of,  837-882 
anatomy  of,  5-8 
atresia  of,  851,  855,  859 
bacteriology,  137-140 
cancer  of,  864 
chorion-epithelioma  of,  866 


Vagina  (cotttinued) : 

cystic  tmnours  of,  860,  861 

dilatation  of,  5,  841 

echinococcus  of,  861 

enterocele  of,  881 

excision  of,  307 

extirpation  of,  603 

fibro-myomata  of,  863,  864 

fistulje  of,  869-882 

formation  of,  807 

hydatid  cysts  of,  860 

malformations  of,  851,  853 

papilloma  of,  866 

prolapse  of,  286-290,  299-302,  860 

retention  of  menses  in,  857-860 

sarcoma  of,  866-869 

sterilization  of,  129 

tuberculosis  of,  629,  630 

varicocele  of,  881 
Vaginal  fixation,  272-277 

pimction,  148-150,  370 
Vaginismus,  837-842 

causation,  838,  839 

diagnosis  of,  840 

examination    of    urine    in,    842, 
843 

symptoms  of,  839 

treatment  of,  840-842 
Vaginitis,  844-851 

follicular,  844 

gonorrhoeal,  846,  848 

granular,  845 

pathology,  846 

simple  acute,  846 

symptoms,  845,  848 

treatment,  845-848 
Vapo-cauterization,  336-342 
Ventro-fixation,  17,  270 
Vulva : 

abscess  of,  3,  826 

affections  of,  798-836 

anatomy  of,  1 

atresia  of,  798 

cancer  of,  808,  820 

cutaneous  affections  of,  809 

cysts  of,  3,  821,  829 

eczema  of,  810-812 

elephantiasis  of,.  830-832 

epithelioma    and    chancroid    of, 
835 

fibroma  of,  809 

gangrene  of,  2,  827 

hematoma  of,  3,  829,  830 

hermaphrodism,  799-837 

hernia  into,  833 

hypersesthesia,  810 

inflammation  of  labia,  826 

kraurosis,  814 

lymphangiectasis  of,  830 

malformations  of,  799-807 

oozing  papillomatous  tumoiu"  of, 
821 


1034 


INDEX. 


Vulva  {continued) : 

operations  on,  820,  828 

pediculi  of,  812 

pruritus,  812-819 

rodent  ulcer  of,  820 

syphilis  of,  819,  821-823 

trachoma  of,  828 

tuberculosis  of,  627 

tumours  of,  821,  829,  832,  836 

varix  of,  829 

warts   and    vegetations   of,    827, 

Vulvitis,  2,  823-826 
causation,  823,  824 


Vulvitis  (continued) : 
diphtheritic,  827 
foUicular,  824 
in  children,  824-826 
purulent,  823 
simple,  823 
symptoms  of,  824 
treatment,  826 

Weir-Mitchell  treatment,  202,  203 

X-EAYS  in  diagnosis,  894,  926 

Zmc  chloride  treatment,  347 


ILLUSTRATIONS    OF  INSTRUMENTS 
AND   APPLIANCES. 


Abdominal  supports,  244 
Adjuster,  Bozeman's,  876 
Angiotribe,  Dowues,  497,  499 

Zweifel's,  510 
Aspirating  needles,  90 
Aspirating  sucker,  796 
Aspirators,  90,  148 

Basket,  metal,  135 
Batteries,  etc.,  1003,  1004 
Bougies,  author's,  82 

rectal,  980 
Box  for  needles,  116 

for  sterilizer,  118 

Cable,  Downes',  498 
Calibrator,  Kelly's,  4,  898 
Cannula,  146,  148 
Catheters : 

glass,  136 

self-retaining,  290 

ureteral,  930 
Cauterv  : 

blades,  499 

handle,  144 

knife,  501 

shield,  500 
Chloroform    regulator,    Vernon-Har- 

court's,  77 
Clamps,  484,  978 
Concuteurs,  1017 
Couches,  57 
Crucible,  155 
Crutch,  58 
Curettes : 

light  metal  spoon,  157 

Martin's,  157 

sharp  spoon,  Simon's,  858 

various  forms  of,  156 
Cystoscope,  896 

Dilators : 

author's,  82,  841 


Dilators  (continued) : 

Bossi's,  443,  444 

for  cervical  canal,  242 

Hegar's,  82 

Leiter's,  82 
Douche,  205 
Drainage  supports,  880 

Elevatoe,  70 
Enucleator,  465 
Erigne,  Doyen's,  490 

Forceps : 

bell-shaped,  337 

clamp,  158,  476,  480,  496 

claw,  516 

combination,  337 

curette,  157 

Doyen's,  483,  485,  527,  531 

dressing,  64 

electro-hsemostatic  (Jacobs'),  496 

hfemostatic,  476 

Kocher's,  495 

morcellation,  469 

Ne'laton's,  793 

Orthmann's,  273 

Pean's,  469 

pile,  976 

speculum,  68 

tenaculum,  65 

tent,  80 

Thompson's,  918 

tube  tranchant,  470 

Well's  torsion,  476 

Zweifel's,  485 
Forehead  reflector,  478 
Fork,  pile,  976 

Helicoid,  489 
Hook,  65 

Insufplatoes,  356 
Irrigator,  731 


1036     ILLUSTRATIONS   OF  INSTRUMENTS  AND  APPLIANCES. 


Knives  : 

Cook's  peritoneal,  477 

fistula,  873 

Hall's,  143 

Landau's,  156 

Martin's  colporrhaiDhy,  300 

Sims',  145 

Lamps,  112 
Lancet  (HaU's),  143 
Lavabos,  113 
Leg  rests,  58 
Ligature  tightener,  524 

Mbdicatoe,  intra-uterine,  154 

Nail  beush,  aseptic,  125 
Needle-box,  116 
Needle-case,  glass,  121 
Needle-holders : 

Doyen's  peritoneal,  481 

Martin's,  275,  520 

Olshausen's,  519 

Schauta's,  520 
Needles  : 

aspirating,  90 

Bryant's,  872 

curved,  276 

Emmet's,  873 

fistulEE,  872 

for  artificial  serum,  114 

Olshausen's,  482,  483 

Eeverdin's,  488 

Zweifel's,  547 

Obtueatoe,  899 
Ointment  positor,  987 

Pessaeies : 

Braun's  colpeurjTiter,  285 

celluloid  cushion,  258 

celluloid  ring,  257 

Fowler's,  238 

Galabin's,  237 

glycerine  pad,  255 

Hewitt's,  238 

Napier's,  285 

Schultze's,  260,  284 

Smith-Hodge,  255 

Zwanck's,  284 
Pipettes,  275 
Polyptom,  author's,  398 
Porte-caustique,  154 
Positor,  rectal  (author's),  987 
Probe,  Sims'  pliable,  69 

rectal,  972 
Proctoscope,  Strauss,  967 

Reels  for  sutures  and  ligatures,  120 
Eeflectors,  478 


Repositors : 

sigmoid,  320 

White's  cup,  320 
Retractors : 

author's  glass,  478 

bladder,  518 

Doyen's  supra-pubic,  476 

fenestrated,  519 

flushing  vaginal,  130 

lateral,  519 

Martin's,  274,  275,  518 

Olshausen's,  521 

Segond's,  479 

ScissoES  : 

blunt-pointed,  496 

broad  ligament,  522 

button-hole,  893 

cautery,  384 

Kuchenmeister's,  145 

pile,  976 
Sounds : 

author's,  69,  70 

Orthmann's,  278 

platinum,  1005 

Simpson's,  69 
Specula : 

author's,  64,  69 

bath,  67 

bladder,  899,  900 

duckbill,  64,  66 

Fergusson's,  66 

Kelly's,  899,  900 

Neugebaur's,  66 

rectal : 

Dav;>''s,  105 
Gowland's,  106 
Ryall's,  105 

Sims',''66 

tapering,  64 

urethral,  899,  900 

various  forms  of,  64-67 
Speculum  slice,  67 
Stems,  author's,  146 
Sterilizers,  117,  119,  134 
Sucker,  Kelly's,  900 
Supports  : 

drainage,  880 

for  legs,  58 

supra-pubic,  244 
Syphon  trocar,  146 
Syringe,  bladder  and  uterine,  106 

Tables,  operation : 

Doyen's,  61 

Grey  Smith's,  115 

nickel  and  glass,  59,  60 

portable,  58 

Trendelenburg's,  115 
Tap  with  abjustable  nozzle,  129 
Temperature  coil  (Leiter's),  329 
Tent  introducer,  80 


ILLUSTEATIOXS   OF  INSTRUMENTS  AND   ATPLIANCES.     1037 


Tents,  80,  81 
Trocaxs : 

aspirating,  148 
for  pelvic  abscess,  149 
Koeberle's,  148 
ovariotomv,  146 
Tait's,  793 
Wells',  146,  792 
Tube  tranchaut.  Doyen's,  470 

Ureteral     instruments     (Howard 
Kelly's)  : 
catheters,  930 
forceps,  930 
guides,  941 


Ureteral  instruments  (Howard 
Kelly's)  {continued)  : 

searcher,  930 

urine  collector,  930 
Urethral  calibrator,  4,  898 
Uterine  probe,  69 
Uterine  tractor,  517 

Vaginal  rest,  841 
Vaginal  vibrator,  1016 

WiEE-catch,  875 
Wire-conductors,  397,  873 
Wire-twister,  875 
Wool-holder,  143 


LIST   OF   AUTHORITIES. 


{See  also  Letterpress  of  Plates.) 


Abel,  K.,  332 

Abraham,  Phineas,  561,  566 

Ackermann,  778 

Adams,  264,  266,  268 

Agello,  630 

Ahlfeld,  125,  139,  251 

Alexander,  William,  264,  266, 267,  268, 

447,  466,  914 
Allan,  Professor,  805 
AUingham,  W.,  974,  979 
Alquie,  264 
Alterthum,  631 
Amann,  586,  621,  635,  778 
Ambler,  H.,  795 
Ambrose,  386 
Amussat,  305,  859 
Anache,  636 
Apostoli,  347,  1005-1007 
Aran,  264,  317,  720 
Aschoff,  606 
Atkins,  Gelston,  30,  748 
Atthill,  Lombe,  153,  180 
Aveling,  318,  319 

Backee,  562 

Backhaus,  742 

Baer,  510 

Baldy,  269,  537,  772 

Bamberger,  263 

Bantock,  Granville,  230 

Bardenheuer,  982 

Barette,  951 

Barker,  Fordyce,  226,  386 

Barlow,  684 

Barnes,  Fancourt,  319,  394 

Barnes,  Eobert,  29,  35,  52,  230,  317, 

318 
Barraclough,  222 
Barrows,  684 
Bataille,  812 
Battey,  R.,  29,  458,  648 
Baudelocque,  314 
Baumgart,  645 
Beach,  606 
Becquerel,  73 


Bell,  Hamilton,  583,  670 

Bergmann,  119 

Berkeley,  Comyns,  620,  623,  628,  629 

Berndt,  882 

Beyea,  630,  862 

Bidder,  400 

Bierfreund,  629 

Bigelow,  6,  912 

Bilroth,  411,  949 

Birsch-Hirschfeld,  630 

Bischofi,  34,  690 

Bishop,  Stamnore,  266,  305,  401,  527, 

539 
Bland-Sutton,  36,  660,  662,  695,  707, 

731,  739,  775 
Blasius,  Gerald,  902 
Bode,  269 
Bohn,  886,  887 
Boldt,  409 
Bonjean,  433 

Bonnet,  161,  332,  333,  656,  657,  729 
Boraveli,  263 
Borgareski,  917 
Bossi,  443 
Both,  Van,  713 
Bouchet,  34 

Bovee,  266,  305,  461,  942-945 
Boyd,  408 
Boyer,  314 
Bozeman,  880 
Brandt,  1013 
Breitenfeld,  856 
Brens,  402 
Briesky,  814 
Brose,  550 
Brouardel,  620,  853 
Broun,  Le  Roy,  263 
Broussais,  401 
Brown,  Bedford,  321,  433 
Browne,  588 
Bruhns,  554 
Buckmaster,'1007 
Bumm,  109,  121,  169,  288,  463,  494, 

596,  658,  749 
Buxton,  Dudley,  76,  77 


LIST  OF  AUTHORITIES. 


1039 


Bvford,  T.  H.  26G,  304,  305 
Byrne  (Brooklyn),  587,  604 

Cambernon, 401 
Carmichael,  376 
Carpenter,  George,  92,  624,  626,  731, 

734 
Garrard,  820 
Carstens,  442 
Cayla,  628 
Cazin,  Maurice,  606 
Charcot,  187 
Cheatle,  Arthur,  408 
Ch6ron,  887 
Chiari,  606,  628 
Christoforis,  620 
Chrobak,  189,  232,  288,  493,  820 
Clado,  904 
Clark,  539,  566,  909 
Clay,  411,  445,  582 
Clemens,  773 
Coe,  442,  562 
Cohn,  264 
Cohnheim,  620,  621 
Collier,  46 

Collins,  Tenison,  758,  912 
Cornil,  332,  333,  620 
Couvelaire,  863 
Cripps,  Harrison,  411 
Croom,  HalUdav,  229,  617,  831,  913, 

914 
Cruveilhier,  22 

CuUen,  415,  416,  419,  586,  631,  778 
Cullin,  T.  S.,  886 
Cullingworth,  409,  637,  712,  769,  857, 

871 
Cunningham,  20,  25,  27,  41 
Curatullo,  39 
Cushing,  332,  602 
Cutter,  E.,  434,  999 
Czemy,  263. 

Daetigues,  768,  772,  776 

Davidsohns,  628 

Davis  (Atalanta),  835 

Delageniere,  262,  263,  264,  266 

Demme,  624 

Deschamps,  628 

Diesterweg,  402 

Doderlein,  137,  288,  332,  388,  596,  600 

Dohertv,  364 

Doleris",  160,  161,  298 

Donald,  442 

Donhoff,  636 

Dookelski,  825 

Doran,  Alban,  400,  412,  653,  654,  669, 

670,  682,  729,  737,  886 
Downes  (Philadelphia),  494-504,  604, 

768,  769 
Doven,  108,  109,  263,  311,  414,  463, 

471,  489,  501,  509,  527,  530-533,  595 
Driessen,  630 


Dsirne,  748,  749,  766 

Dudley  (Chicago),  209,  243,  880 

Duhrssen,  265,  274,  298,  322,  603,  624, 

689 
Dumaire,  556 
Dmnontpallier,  347 
Duncan,  Jlatthews,  192,  317,  360,  361, 

408,  627,  628,  729,  837,  854 
Duncan,  William,  439 
Duplay,  834,  887 
Dupuytren,  859 
Duret,  322,  830 

ECKHAEDT,  663,  778 

Edebohls,  264,  268,  288,  843,  945,  956, 

957 
Eden,  617 
Edge,  34,  35,  272,  298,  414,  459,  463, 

646 
Edis,  849 

Edwards,  Swinford,  973 
Ehrendorfer,  408,  525 
Ehrenfest,  Hugo,  600,  624 
Emanuel,  622,  630,  631 
Emmet,  30,  302,  318,  359,  360,  385, 

386,  730,  821,  842,  885,  892,  907 
Engelmann,  34,  226, 229,  442,  996,  997, 
Englisch,  35,  886 
Erlenmeyer,  199 
Eschof,  420 
Ewald,  92 

Falk,  382,  707,  742 
Farmer,  Bretland,  551 
Par  re,  357 

Fam-e  (Paris),  463,  464,  505,  645,  646 
Fehling,  35,  74,  600,  714 
Feitel,  938 

Fenger,  Christian,  945 
Ferguson  (Manitoba),  876 
Ferrier,  587 
Finlay,  D.,  412 
Finn,"  347 
Fisch,  607 
Fischel,  332 
Fischer,  787 
Fitz,  366 
Flatau,  414,  415 
Flaischlen,  262,  778 
Fleischmann,  618 
Fliess,  189,  251 
Floriep,  667 
Fort,  Le,  304 
Foulerton,  658 
Fournel,  160,  266 
Fraenkel,  630 
Frank,  872 

Franks,  Kendal,  347,  411 
Frederik,  409 
Fredrichs,  636 

Freund,  264,  266,  288,  305,  372,  505, 
584,  802,  881 


1040 


LIST  OF  AUTHORITIES. 


Freyer,  P.  J.,  913 

Henle,  28 

Freyhau,  125,  139 

Hennig,  680 

Frick,  869  " 

Herman,  714 

Fritsch,  251,  336,  544,  821,  970 

Hermann,  887 

Frommel,  305 

Herrick,  266,  305 

Fuerbringer,  125,  139 

Herts,  400 

Funke,  586 

Hewitt,  Graily,  187 

Fiith,  263,  902 

Hewlett,  138 

Hey,  887 

Gaeetner,  628 

Hildebrandt,  433 

Galabin,  658,  707 

Hilton,  839 

Galippe,  402 

Hirst,  317 

Gareean,  922 

His,  27,  86,  690 

Gebherd,  650 

Hitschmann,  564 

Gellhorn,  553,  554,  585 

Hobbs,  227,  228 

Gemmel,  643 

Hockenegg,  Von,  604 

Germont,  570 

Hofmeir,  441,  586 

Gersuny,  892 

Hofmeister,  120 

Gessner,  772 

Hohl,  263 

Geyl,  862 

Hollander,  576 

Giel,  629 

Hoist,  Von,  35 

Giles,  Arthui',  408 

Homans,  230,  773 

Giraud,  887 

Homesse,  891 

Glatter,  563 

Hook,  Van,  941 

Godfrey,  854 

Howard,  78 

Goelet,  950 

Hubrecht,  608,  695 

Goffe,  414 

Hulke,  719 

Goldspobn,  262,  264 

Hunner,  911 

Goodell,  9,   147,  205,  218,   235,  254, 

Hutchinson,  628 

314,  386,  818 

Hyrtl,  85 

Goodsall,  978 

Gorovitz,  623 

Ingraham,  652 

Goth,  207 

Irish,  586 

Gottscbalk,  207,  401,  403,  606,  621 

Issmer,  38 

Graefe,  679 

Gross,  993 

Grunbaum,  932 

Jacobs,  266,  304,  415,  449,  497,  503 

Griinfeld,  47 

Jaggard,  319 

Guerin,  847 

Jayle,  232,  745,  1014 

Gulmi,  855 

Jeannel,  606 

Jeil,  620 

Hacker,  445 

Jellett,  867 

Hall,  228 

Jenner,  952 

Halle,  904 

Jessett,  266,  408,  414,  494,  588,  598 

Handfield-Jones,  868 

Johnstone  (Cincinnati),  741 

Handley,  Sampson,  669,  670,  672 

Johnstone,  A.,  36 

Hannah,  184 

Jones,  Mary  Dixon,  229, 402,  408, 411, 

Hansemann,  620 

"412,  453,  555,  556,  648,  677, 724,  786, 

Hanser,  402 

776,  777,  783 

Harcourt,  Vernon,  76,  77,  78 

Jordan,  Furneaux,  322,  558,  585,  863 

Hardon,  355,  360 

Jordan  (Heidelberg),  600 

Hart,  Mrs.  E.,  203 

Hartmann,  109,  361,  905 

Kaltenbach,  321,  600,  606,  838 

Haultain,  604,  614,  615 

Karagan,  624 

Haviland,  718 

Kay,  577 

Hawley,  N.  J.,  265 

Kehrer,  322,  328 

Hayes,  1007 

Keifer,  401 

Hegar;  16,  17,  173,  174,  226,  230.  302, 

Keith,  2.30,  454,  1001 

445,  448,  466,  606,  620,  626,  838 

Keith,  George,  243 

Heiberg,  749, 

Keith,  Skene,  411 

Heitzmann,  555,  575 

Kelen,  967 

Helier,  766 

Kellpg,  263 

LIST  OF  AUTHORITIES. 


1041 


Kelly,  Ho^Yal•d,  5,  47,  lOG,  2G3,  2G5, 
266, 281, 295,  296,  370,  409,  423, 440, 
447, 461,  464,  466,  468, 505,  509,  512, 
513, 522,  523,  539,  546,  565,  587,  600, 
601, 624,  684, 733,  746,  748,  790, 807, 
820,  825,  833,  860,  881,  895,  897-909, 
911,  918-945,  966 

Kimdral,  636 

Kinkead,  11 

Kiwisch,  562,  620 

Klebs,  400,  403,  559 

Klein,  Gustav,  109,  402 

Kleiuhans,  622 

Kleinwiichtei-,  403,  404,  863 

Klob,  247,  313 

Kuauer,  38,  648,  658 

Knox,  Mason,  421,  423 

Koblanck,  269 

Kocher,  263,  268,  982 

Kochs,  199 

Kceberle,  407 

Kohn,  262 

Kolliscber,  600 

Kortright,  836 

KrOnig,  109, 118, 119, 137,  263,  505,  586 

Krugenberg,  775 

Kuhue,  263,  269 

Kundrat,  34,  624 

Kiister,  915 

Kiistner,  263,  264,  269,  287,  321,  323 

Kiittner,  628 

Labadie-Lageaye,  161 

Labourand,  828 

Lacroix,  606 

Landau,  109,  264,  832,  370,  415,  463, 

533,  909 
Landois,  34 
Lange,  889 
Langenbeck,  264,  314 
Lannelongue,  887 
Lavalette,  de  la  Croix  de,  1014 
Lehmann,  636 
Lemiere,  36,  652 
Lenn,  402 
Leopold,  G.,  35,  36, 109,  265,  308,  371, 

509,  556,  691,  693,  695,  768,  778,  847 
Leukardt,  35 
Lewers,  630 

Ley,  Rooke,  222,  223,  229 
Lindfors,  645 
Lister,  109 
Lockyer,    Cuthbert,   711.      See    also 

various  pathological  reports 
Lomer,  584 

Lookascliivitsch,  38,  39 
Louber  (Paris),  468 
Louis,  620 
Luschka,  305 

Macalistee,  723 

Mackenrodt,  265,  274,  555,  1001 


Maclarcn,  A.,  41 

Madden,  Uore,  838,  842 

Madeleuer,  Max,  642 

MafEucci,  623 

Magill,  660,  661 

]\Iahomed,  862 

Maier,  606 

Mainzer,  232,  749 

Mandl,  266,  305,  690 

Maugiagalli,  16,  17 

Mann,  Matthew,  264,  266,  367, 904,922 

Manucll,  862 

Mansell-]Moullin,  203 

Mantegazza,  990 

Manton,  W.,  957 

Marchand,  606,  778 

Marci,  162 

Marion,  860,  861 

Markwald,  304 

Marmorek,  187 

Marro,  648 

Martin,  A.,  109, 118, 130,  229,  265,  274, 
287,  288,  302,  370,  409,  412, 414,  454, 
466,  594,  600,  602,  603,  620,  621,  630, 
636,  652,  787,  814,  859,  1001 

Martin  (Chicago),  263,  264,  446,  456, 
636,  880 

Martin,  Christopher,  37, 160,  229,  414, 
804 

Martm,  F.  H.,  39 

Martin  (Philadelphia),  263 

Marx,  733,  735 

Matthews,  630 

Maude,  Arthur,  805 

MaunseU,  482 

McClintock,  207,  318,  378,  391,  439, 
570 

McCome,  J.  F.,  38 

McCoy,  423 

Meinert,  589 

Melchoir,  904 

Mendes  de  Leon,  141 

Meniere,  437 

Meuge,  109,  139,  190,  414,  477,  586 

Meng-us,  30 

Merletti,  620,  630,  631,  642,  642,  646 

Merrinian,  862 

Meyer,  J.,  35,  402 

Michaelis,  630 

Mikulicz,  133 

Miranoff,  35 

Moclaire,  836 

Monprofit,  654 

Montgomery,  409,  628,  944 

Moore,  J.,  551 

Morax,  361 

Morell-LaYalle,  35 

MorgagTii,  620 

Morisani,  322 

Morlev  (Michigan),  749 

Morris,  Henry,  868,  945,  961 

Morris,  Malcolm,  628 

3  X 


1042 


LIST   OF  AUTHORITIES. 


Muench,  917 

Muller,  265,  272,  307,  403,  606 

Mund6,  P.,  386,  550,  588 

Muret,  232 

Murphy,  620,  623,  624,  628-630,  636- 

638,  642 
Muscatello,  539 

Nagel,  402,  729 
Naunyn,  92 
Negrier,  34 
Negri,  Luigi,  263 
Neisser,  138 
'N^laton,  378 
Nettleship,  100 

Neugebauer,  68,  799,  800,  805,  806 
Newman,  47,  138,  263,  268,  269 
Nicholson,  251,  264 
Nicol^tis,  304 
Nimias,  620 
Noble,   Charles,   174,   269,    409,   488, 

509,  604,  808,  888,  926,  940 
Noeggerath,  319,  387 
Nov^-Josserand,  606 

CEhlecker,  587 
Oldham,  35 
Oliver,  74,  417 

Olshausen,  109,    161,   268,    445,  553, 
586,  587,  600,  603,  662,  710,  745,  820 
Orgler,  766 
Orkqvist,  808 
Orthmann,  640,  642 
Otis,  912 
Ott,  von,  586 
Ostroschevitch,  32 

Paget,  Stephen,  750 

Pallen,  386 

Paulsen,  620 

Paviot,  606 

Pavy,  74 

Pawlik,  47,  590,  892 

P6an,  304,  411 

Pennington  (Chicago),  582 

Penrose,  624 

Peraire,  388,  623 

Percy,  891 

Pestalozza,  606 

Peters,  Carl,  263,  819 

Peterson,  R.,  321,  323,  864 

Petit,  Paul,  332,  333,  635,  646,  655, 

657,  721,  727,  729 
Pfliiger,  35 
Phillips,  John,  864 
Piccoli,  322 

Pick,  576,  617,  676,  742 
Piedpretnier,  887 
Pilliet,  403 
Pincus,  336,  341 
Pinner,  622 
Piser,  554 


Plimmer,  353 

Poirier,  554 

Polity,  821 

Polk,  648,  684 

Pomorski,  778 

Popoff,  623 

Porro,  441 

Posner,  620 

Potal,  864 

Poten,  125 

Poullet,  161 

Poverlein,  629 

Pozzi,  164,  265,  429,  635,  646,  655,  853 

Priestley,  887 

Prochownick,  409,  410,  411 

Pryor,  442,  505,  510,  523,  524,  926 

Puech,  435 

Purefoy,  408 

Raciboesky,  34 

Rainey,  18 

Rauscher,  859 

RajTiaud,  620 

Recklinghausen,  Von,  419 

Regnier,  189 

Reichert,  35,  36 

Reineicke,  125 

Reverdin,  836 

Reymond,  660 

Reynolds,  442 

Rheinstadter,  347,  820 

Richet,  14 

Rieder,  886 

Ries,  Emil,  552,  553,  555,  662 

Rissman,  251,  262 

Roberts,  Hubert,  680 

Robinson,  Byron,  36 

Robson,  Mayo,  408,  695,  713,  945 

Roesger,  401,  403 

Roger,  905 

Roh6,  229 

Rokitansky,  313,  577,  680,  769,  974, 

1000 
Rommel,  860 
Rose,  720 
Rosen,  463 
Rosenhein,  563 
Rosental,  556 

Rosthorn,  Von,  596,  636,  778 
Rouget,  34 

Routh,  588,  887,  999,  1005 
Rubeska,  868 
Ruge,  C,  352,  550,  559 
Rumpf,  263 

Russell  (Baltimore),  554,  558 
Russell,  W.  W.,  675 
Ryall,  Charles,  408,  627 

Sampson,  938  - 
Sanchez,  388 

Sanger,  47,  109,   266,  804,  805,  367, 
445,  556,  605,  606,  813,  814,  820,  868 


IJST  OF  AUTHORITIES. 


1013 


Sappoy,  14,  554 

Savage,  230 

Saver,  415 

Scanzoni,  352,  851 

Schaffcr,  1001 

Scharliob,  Marv,  408,  454 

Schauta,  39,  109,  229,  287,  370,  414, 

4G3,  525,  563,  589,  594,  797,  1013 
Sohmorl,  636 
Schramm,  636 
Schenk,  414,  424 
Scheurlen,  556 
Schlagcuhaufer,  607 
Schlange,  542 
Schmauch,  864 
Schmit,  Von,  563,  577,  690 
Schorlcr,  404 

Schottlander,  643  i 

Schrieber,  969 
Schrceder,  32,  226,  292,  331,  352,  357,    i 

386,  412,  429,    445,  562,  577,   587,    ; 

588,  648,  820,  834,  854 
Schuchardt,  596,  600,  869  | 

Schucking,  269 
Schiiller,  5 

Schultze,  15,  47,  245,  247,  305,  1013 
Seitz,  Otto,  868 
Sellheim,  626 
Seun,  620 

S^quard,  Brown,  39 
Sharpey,  2 
Shattock,  568,  670 
Shawe,  Claye,  222 
Shaw-Mackenzie,  334 
Sherrington,  796 
Shober,  640,  690 
Simon,  4,  91 
Simpson,  A.  R.,  577,  820 
Simpson,  Christian,  230 
Simpson,  Sir  J.,  985 
Sims,  Marion,  18,  67,  209,  299,  302, 

317,  588,  843,  847,  913,  990 
Sinclair,  J.  W.,  229,  589,  707 
SingaUi,  772 
Sippel  (Frankfort),  645 
Siredy,  581 

Skene,  A.,  11,  449,  502 
Slavjansky,  35,  724 
Slocmn,  Harris,  265 
Smith,  Albert,  365 
Smith,  Alfred,  550 
Smith,  AUan,  902 
Smith,  C.  T.,  578 
Smith,  Greig,  539,  945,  956,  961 
Smith,  HevAVOod,  719,  731 
Smith,  Lapthorn,  41,  229,  230,  263, 

266,  268,  269,  919,  958 
Smith,  Rudolph,  705 
Smith,  Tvler,  26 
Smyly,  W.,  534,  635 
Sn^gireff,  336 
Spanton,  962 


Speath,  642 
Spicgclberg,  572,  868 
Spinelli,  323 
Springer,  629 
Stauder,  773 
Stehmann,  640 
Stirling,  34 
Stocker,  263 
Stolper,  631,  635 
Stone,  565 

Strassmann,  34,  35,  690 
Strauss,  388,  570 
StroganofE,  139 
Swatmau,  537 
Swayn,  J.,  365 

Tait,  Lawson,  29,  36,  230,  288,  292, 
298,  394,  425,  445,  466,  648,  649,  670, 
690,  724,  758,  795,  807,  810,  887 

Targett,  707,  867,  953.  Sec  also 
various  pathological  reports 

Tarulli,  39 

Taylor,  F.,  418 

Taylor,  J.  C.  (Birmingham),  269,  313, 
323,  389,  659,  690,  695,  700,  701, 
710,  712,  715,  997 

Teacher,  607,  610-613,  616 

T6denat,  364 

Terillon,  642 

Terrier,  F.,  109 

Thiede,  550 

Thiry,  620 

Thomas,  Gaillard,  288,  316,  810,  843, 
868 

Thorns  (Magdeburg),  713 

Thornton,  Knowsley,  945-960,  952 

Thumin,  441 

Tilt,  226 

Toledo,  388 

Trendelenburg,  881 

Tridondani,  401 

Tripier,  989 

Trommer,  74 

Tuffer,  79 

Tussenbroek,  Van,  691 

Uhlman,  543 

Van  Beuen,  984 

Vassmer,  431,  630 

Veit,  38,  247,  262,  263,  832,  398,  550, 

569,  622,  714,  815,  943 
Velits,  Von,  778 
Verdier,  35 

Vemeuil,  620,  621,  980 
Viattel,  628 
Vignard,  772,  773 
Viguier,  773 
Villard,  269 
Vinay,  766 
Vineberg,  265,  266,  277 


1044 


LIST   OF  AUTHOBTTIES. 


Virchow,  R.,  400-402,  411,  412,  555, 

556,  577,  733 
Voigt,  402,  778 
Vries,  de,  861 
VuUiet,  248,  588 

Wahl,  541 

Waldever,  35,  554,  559,  572 

Walker,  C.  E.,  551 

Wallace,  362 

Walter  (Manchester),  741,  755,  866 

Walton,  161 

Watson,  Morrison,  46 

Webster,  C,  398,  412,  695 

Webster,  J.  C,  813 

Wecker,  L.  de,  99,  100,  103 

Wehmer,  414 

Weir-Mitchell,  203,  351 

Weiss,  749,  766 

Wells,  Spencer,  230,  411,  425,  466,  588, 

761,  763,  864,  949 
Werder,  599 
Werthe,  35 
Wertheim,  269,  305,  587.  590,  596,  601. 

658 
Whitacre,  633 


White,  Clement,  667 

WTiitehead,  W.,  184,  978 

Wiglesworth,  227 

Wilks,  52 

Williams  (Philadelphia),  630 

WiUiams,  Eoger,  30,  34,  36,  401,  576, 

577,  640,  861,  862,  864,  869 
Williams,  ^^^aitridge,  628,  825 
Williams,  Wynn,  588 
Williamson,  Herbert,  705 
Wilson,  Thomas,  738 
Winckel,  550,  636,  653,  939 
Winter,  G.,  586,  600 
WitzeU,  943 
WolfE,  308 
Wolffler,  445,  603 
Won-all  (Sydney),  411 

Yellowlees,  223 
Ytmg,  815 

Zagoejaxski,  618 
Zeigbaum,  628 
Zuckerkandl,  603 

Zweifel,  Paul,  109,  119,  385.  460,  509, 
535,  543,  586,  596 


THE   END. 


PEKTED  BY  WILLIAM   CLOWES   AXD  SOSS,  LIMITEP,   LONDON   AKD   BF.CCLES. 


~\^Gr\0\ 


'^^^^,^^"^ 

X'?)©^ 


